الفهرس 
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Abstract
Hepatic encephalopathy (HE) is one of the neuropsychiatric complication hat occur in patients with hepatic cirrhosis. When cognitive impairment s are subtle and only detected by psychometric assessment, it is called minimal hepatic cirrhosis MHE.
Patients with MHE are considered to be a burden , they have poor quality of life, are more vulnerable to road traffic accidents and labor accidents. MHE can be an indicator of future episodes of overt hepatic encephalopathy that decrease the expected survival of the patients, that is why early detection of MHE among the cirrhotic patents is considered important to prevent more serious consequences.
There was no consensus over a protocol to diagnose MHE . in 1998 at the 11th World Congress of Gastroenterology, Vienna, the PHES had been approved for diagnosis of MHE. In addition of neurophysiology tests(VEP, SSEP, BAEP, EEG) that became largely acknowledged for detecting the cortical changes that occur with HE.).
In our study, our aim was detection of MHE among a group of compensated cirrhotic patients (child A) by using mfVEP and 2 additional psychiatric tests (PAL, BVRT) and compare their results with the usually used tests for MHE diagnosis (PHES, PVEP).
The PHES had detected MHE in 14 patients (31%) of the cirrhotic group. And on that basis we subdivided the cirrhotic groups into two subgroups (MHE patients that include 14 patients) and non MHE subgroup that include 31 patients who were supposed to be completely free.
The mfVEP had detected abnormalities in 15 patients (13 of them had abnormal PHES and one case had normal PHES). The abnormalities were mainly of delayed latencies and to less degree amplitude affection.
The mfVEP was able to detect subtle abnormalities in patients with no MHE in comparison to control group (regarding latency and amplitude), despite they were scored as normal according to our calculated cut off.
The PVEP was tested by 2 check sizes, the large check size (1 degree) had found abnormalities in 6 patients in the cirrhotic group (all of them had abnormal PHES) and all abnormalities was because of delayed latencies, no amplitude attenuation was detected.
The PVEP small check size (15 min) detected abnormalities in 13 patients in the cirrhotic group (all had abnormal PHES), abnormalities were mainly of delayed latencies and to less degree amplitude affection.
Only small check size VEP (15 min) had found subtle abnormalities over the non-MHE patients when compared to controls (regarding latency). despite they were scored as normal according to our calculated cut off.
With Benton test, 11 patients of the cirrhotic group had shown abnormal results . The BVRT had found subtle abnormalities in the patients with no MHE, despite they were scored as normal according to our calculated cut off.
With PAL test, detected abnormalities in 10 patients in the cirrhotic group (all had abnormal PHES. There was no significant difference between non-MHE patients and the control group detected by pal.
The highest sensitivity for detection of MHE is 92.9%, by mfVEP and small check size VEP (15 min), then the Benton and PAL test with a sensitivity of 78.6% and 71.4% respectively. And the lower sensitivity was for the VEP large check size (1 degree) with a sensitivity of 42.9% .
The mfVEP showed a strong agreement with the validated PHES 93.3%. and it had detected abnormalities in 2 cases that were considered free by the PHES. in our opinion these 2 cases are highly recommended for follow up for detection of any future insult may develop .
The mfVEP, PVEP small check size (15 min) and the Benton test were able to detect subtle abnormalities in the non MHE group when compared to controls , this is noteworthy because all the non-MHE cases had scored as normal regarding each test. Further research for this point is recommended.
Unlike PHES, the neurophysiological tools are objective methods that are not affected with level of education, don’t have bias of repeatability, so they can be used for follow up and in cases of illiteracy/ low level of education.
In conclusion, The mfVEP was proven to be sensitive in detection of MHE with strong agreement with the validated PHES.
We propose that a combination of neurophysiology (mfVEP / small check size PVEP) with the PHES, can detect the slightest changes and lead to early detection of MHE and that surely will help in prevention of more serious complications.
Memory affection (especially the visual memory have been proved even in Patients that are considered MHE free.