QuickStroop for screening for minimal hepatic encephalopathy in patients with cirrhosis
Christian Labenz,
Simon J. Gairing,
Leonard Kaps,
Alena F. Ehrenbauer,
Eva M. Schleicher,
Sophie Mengel,
Julius F.M. Egge,
Maria M. Gabriel,
Peter R. Galle,
Heiner Wedemeyer,
Alexander Zipprich,
Cristina Ripoll,
Robin Greinert,
Benjamin Maasoumy
Affiliations
Christian Labenz
Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Corresponding author. Address: Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Langenbeckstrasse 1, 55131 Mainz, Germany. Tel: +49 6131 17 2380; Fax: +49 6131 17 477282.
Simon J. Gairing
Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Leonard Kaps
Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Alena F. Ehrenbauer
Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
Eva M. Schleicher
Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Sophie Mengel
Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Julius F.M. Egge
Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
Maria M. Gabriel
Department of Neurology, Hannover Medical School, Hannover, Germany
Peter R. Galle
Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany; Cirrhosis Center Mainz, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany
Heiner Wedemeyer
Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
Alexander Zipprich
First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany; Internal Medicine IV, Jena University Hospital, Jena, Germany
Cristina Ripoll
First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany; Internal Medicine IV, Jena University Hospital, Jena, Germany
Robin Greinert
First Department of Internal Medicine, Martin-Luther University Halle-Wittenberg, Halle, Germany
Benjamin Maasoumy
Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
Background & Aims: QuickStroop, a shortened version of the Stroop EncephalApp, has recently been proposed for screening for minimal hepatic encephalopathy (MHE) in patients with cirrhosis in the USA. At present, there are no data on its clinical utility for MHE screening in patients in Europe, and only limited data are available regarding its comparison to the Animal Naming Test (ANT). Methods: In total, 242 patients with cirrhosis without signs of hepatic encephalopathy (HE) ≥ grade 1 and no history of overt HE were included as the development cohort. Another independent cohort comprising 104 patients with cirrhosis from a different center served as a validation set. MHE was defined using the psychometric hepatic encephalopathy score (PHES) (PHES-MHE). All patients were tested with the complete EncephalApp Stroop. A subset was also tested with the ANT. Regression formulas were fitted for patients above and below the age of 60 years, including the first two off-state runs, age, and school education (QuickStroop). Results: PHES-MHE was detected in 76 (31%) patients. The first two off-state runs of the EncephalApp demonstrated a comparable discriminative ability to the complete Stroop test in distinguishing between patients with and without PHES-MHE. QuickStroop had a better discriminative ability in patients below than above the age of 60 years. The discriminative ability of QuickStroop (total cohort: AUC 0.88) was superior to ANT (AUC 0.70). QuickStroop predicted PHES-MHE with a sensitivity of 74% and a specificity of 89%, and took a median of only 34.5 s to complete. The acceptable discriminative ability of QuickStroop was confirmed in the validation cohort (AUC 0.81). Conclusion: QuickStroop is a rapid screening tool to identify patients at risk for PHES-MHE, especially in patients below 60 years of age. Impact and implications:: QuickStroop, a shortened version of the Stroop EncephalApp, has recently been proposed for screening for MHE in patients with cirrhosis in the USA. In this study, we validated QuickStroop for patients in Germany with cirrhosis and demonstrate a good diagnostic accuracy for detecting MHE, especially in patients below 60 years of age. Additionally, QuickStroop might be superior to the ANT in patients below 60 years of age. The use of QuickStroop in clinical practice could facilitate screening for MHE.
