Overt hepatic encephalopathy impairs learning on the EncephalApp stroop which is reversible after liver transplantation

Liver Transpl. 2017 Nov;23(11):1396-1403. doi: 10.1002/lt.24864.


After an initial exposure, patients can develop test-taking/learning strategies called the "test sophistication effect." Patients with cirrhosis with prior overt hepatic encephalopathy (OHE) could have persistent learning impairments. The aim was to define learning/test sophistication on EncephalApp (downloadable application) in OHE patients compared with patients without prior overt hepatic encephalopathy (no-OHE) patients and controls cross-sectionally and longitudinally. The EncephalApp Stroop App consists of 2 sections: the easier "Off" run assesses psychomotor speed while the difficult "On" run assesses cognitive flexibility. For the cross-sectional analysis, outpatients with cirrhosis with/without controlled OHE and healthy controls underwent EncephalApp testing, which requires 5 Off and 5 On runs. We studied the difference in time required between completing trial 1 compared with trial 5 (delta 1-5) in both the On and Off runs in controls, all patients with cirrhosis, and between prior OHE/no-OHE patients with cirrhosis. For the longitudinal analyses, 2 groups of patients with cirrhosis were studied; 1 was administered the EncephalApp ≥ 2 weeks apart, and the second was administered before and 6 months after liver transplantation. The study included 89 controls and 230 patients with cirrhosis (85 prior OHE; Model for End-Stage Liver Disease, 11) with similar age (64 versus 61 years; P = 0.92). Patients with cirrhosis had impaired EncephalApp total times and impaired learning on the On runs compared with controls. OHE patients had worse EncephalApp times and learning with the On runs compared with no-OHE patients, which persisted in the longitudinal cohort. No differences in learning were seen in the Off runs. After transplant, there was restoration of learning capability with the On runs in the OHE patients. In conclusion, cognitive flexibility tested by the EncephalApp On runs improves over time in healthy controls and no-OHE but not prior OHE. Psychomotor speed remains similar over time. The learning impairment manifested by patients with cirrhosis with OHE is restored after transplant. Liver Transplantation 23 1396-1403 2017 AASLD.

Publication types

  • Research Support, U.S. Gov't, Non-P.H.S.
  • Research Support, N.I.H., Extramural

MeSH terms

  • Aged
  • Cognition Disorders / etiology
  • Cognition Disorders / psychology*
  • Cognition Disorders / surgery
  • Cross-Sectional Studies
  • End Stage Liver Disease / complications
  • End Stage Liver Disease / surgery*
  • Female
  • Hepatic Encephalopathy / complications
  • Hepatic Encephalopathy / surgery*
  • Humans
  • Learning*
  • Liver Cirrhosis / complications
  • Liver Cirrhosis / surgery*
  • Liver Transplantation*
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Prospective Studies
  • Psychometrics
  • Psychomotor Performance
  • Severity of Illness Index
  • Software
  • Test Taking Skills
  • Time Factors