The important effort is to engage in testing rather than awaiting standardization. Regarding choice of MHE tests complete standardization is at present not possible and in view of the diversity of MHE patients perhaps not even desirable. 1, 2, 3 No strategy is universally more correct than the one validated in its target population. 5 Diagnostic approaches and treatment decisions vary between continents, countries and centers. The mainstay of the standard treatment remains the efficient, safe, and cheap drug lactulose, which may be supplemented with branched chain amino acids or rifaximin in difficult-to-treat cases. This unsatisfactory status needs to be improved by clarification of the doubts mentioned so that more patients in need get the treatment. 1 Together, the effects of such factors deprive the majority of MHE patients of the available efficient anti-HE treatment. 1, 2 These doubts go hand in hand with structural arguments about prioritizing time and staff for the purpose ( Figure 1). 1, 2, 3 The hesitation is rooted in doubts about which tests to use, lack of knowledge about treatment benefits, and uncertainty about the tests’ ability to identify patients who will benefit from anti-HE treatment. While nearly half of hepatologists seem to engage in MHE testing only 10% systematically examine their cirrhosis populations. some sort of psychometry) is offered only to selected cirrhosis patients. The real world scenario is still characterized by hesitation and MHE testing (i.e. Minimal Hepatic Encephalopathy (MHE) is a serious and frequent problem for many cirrhosis patients but still far from all cases of MHE are diagnozed and treated.

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