Minimal hepatic encephalopathy (MHE) is the mildest type of hepatic encephalopathy (HE) and is considered a preclinical stage of HE. It is part of a wide spectrum of typical neurocognitive alterations commonly found in patients with liver cirrhosis, particularly involving the areas of attention, alertness, response inhibition, and executive functions. 

MHE is diagnosed by testing the patients′ psychometric performance, attention, working memory, psychomotor speed, and visuospatial ability, along with electrophysiological and other functional brain measures. MHE affects 20% to 80% of patients tested, depending on the diagnostic tools used. Although subclinical, MHE is clinically relevant. Interestingly, it has been related to the patients′ falls, fitness to drive, and working ability. As a result, MHE affects the patients′ and caregivers′ lives by changing their quality of life and socioeconomic status. 

Recently sarcopenia, a widespread condition in patients with advanced liver disease, has shown an association with both minimal and overt HE. 

A review by Nardelli S. et al. summarized the latest published evidence about the emerging relationship between sarcopenia and cognitive impairment in cirrhotic patients and furnished suggestions for future research.

They hypothesized that clinical effects attributed until now to the presence of MHE might be partially or totally explained by the contemporary presence of sarcopenia. The falls, which are frequently reported in cirrhotic patients with MHE, could be due to sarcopenia and their functional consequences. The same could be possible for reduced driving capacity and car accidents. Even the reduced working capacity may be the consequence of muscle alterations. This hypothesis demands studies to back up, in which the contemporary assessment of the quantity, quality, and functionality of the muscle mass are coupled with the assessment of the cognitive impairment. 

Moreover, recent studies have shown improvement in the nutritional assessment after physical exercise in patients with cirrhosis, but no study has investigated the modifications of cognitive impairment after physical activity. Thus, cirrhotic patients management could also be seen from a new perspective. In fact, ameliorating nutritional status may be an achievable goal to lower the prevalence of MHE and its clinical consequences.

Nardelli S, Gioia S, Faccioli J, Riggio O, Ridola L. Sarcopenia and cognitive impairment in liver cirrhosis: A viewpoint on the clinical impact of minimal hepatic encephalopathy. World J Gastroenterol. 2019 Sep 21;25(35):5257-5265. doi: 10.3748/wjg.v25.i35.5257. PMID: 31558871; PMCID: PMC6761233.