Minimal hepatic encephalopathy in hepatosplenic schistosomiasis: High prevalence and association with portosystemic shunts in a Brazilian cross-sectional study

Table 1 Demographic and clinical characteristics of 200 patients with hepatosplenic schistosomiasis (Recife, Brazil, 2025)

Variable	mean ± SD or n (%)
Mean age (years)	56.44 ± 13.31
Female sex	106 (53.00)
Self-reported ethnicity
Black	148 (74.00)
White	52 (26.00)
Average education (years)	4.88 ± 3.47
Illiteracy	17 (8.50)
Functional illiteracy	117 (58.50)
Previous splenectomy	94 (47.00)
Mean HAD score	7.88 ± 2.16
Mean MMSE score	25.42 ± 0.81

HAD: Hospital Anxiety and Depression Scale; MMSE: Mini-Mental State Examination.

Table 2 Prevalence of hepatic encephalopathy diagnosis through animal naming test in 200 patients with hepatosplenic schistosomiasis

Variable	n (%)
Overt hepatic encephalopathy	1 (0.50)
Minimal hepatic encephalopathy (positive animal naming test)	48 (24.00)

Table 3 Distribution of 200 patients with hepatosplenic schistosomiasis with and without hepatic encephalopathy, diagnosed by animal naming, according to the presence or absence of portosystemic shunts (Recife, Brazil, 2025)

Encephalopathy portosystemic shunts	Yes (%)	No (%)	Total (%)	P value
Yes	33 (67.30)	78 (51.60)	111 (55.50)	0.0018
No	16 (32.60)	73 (48.30)	89 (44.50)
Total	49 (24.50)	151 (75.50)	200 (100)

Data are showed as n (%).

Table 4 Clinical characteristics of 200 patients with hepatosplenic schistosomiasis, according to the presence or absence of hepatic encephalopathy diagnosed by animal naming (Recife, Brazil, 2025)

Variables	Total (%)	With HE, n = 49 (%)	Without HE, n = 151 (%)	P value
Average age (years)	56.44 ± 13.31	57.55 ± 13.96	56.08 ± 13.08	0.52
Female sex	106 (53.00)	33 (67.35)	73 (48.34)	0.03
Self-reported ethnicity
Black	148 (74.00)	38 (77.55)	110 (72.84)	0.68
White	52 (26.00)	11 (22.45)	41 (27.15)
Education (years)	4.80 ± 3.47	4.50 ± 4.35	5.21 ± 3.06	0.14
History of UGIB	127 (63.50)	34 (69.38)	93 (61.58)	0.41
Previous splenectomy	94 (47.00)	21 (42.86)	73 (48.34)	0.61
HAD questionnaire score	7.88 ± 2.16	7.69 ± 3.79	7.94 ± 2.50	0.83
Mean MMSE score	25.42 ± 0.81	24.06 ± 1.17	26.04 ± 0.63	0.0003
MMSE < 25	73 (36.50)	28 (57.14)	45 (29.80)	0.001

Data are showed as n (%) or mean ± SD. UGIB: Upper gastrointestinal bleeding; HAD: Hospital Anxiety and Depression Scale; MMSE: Mini-Mental State Examination; HE: Hepatic encephalopathy.

Table 5 Comparison between the presence of hepatic encephalopathy (according to animal naming) and laboratory parameters in 200 patients with hepatosplenic schistosomiasis (Recife, Brazil, 2025), mean ± SD

Variables	Total	With HE, n = 49	Without HE, n = 151	P value
Total bilirubin	1.20 ± 0.76	1.19 ± 0.77	1.19 ± 0.76	0.98
INR	1.20 ± 0.05	1.22 ± 0.23	1.20 ± 0.21	0.46
Albumin	4.02 ± 0.48	3.97 ± 0.57	4.04 ± 0.44	0.40
Alkaline phosphatase	128.83 ± 74.50	150.75 ± 63.00	120.96 ± 77.00	0.06
Platelets (× 109/L)1	75846 ± 48000	75000 ± 48000	77000 ± 45000	0.87
APRI1	2.00 ± 2.17	2.21 ± 0.50	1.93 ± 1.40	0.64
FIB-41	6.24 ± 4.06	7.08 ± 0.30	5.93 ± 3.40	0.27
Coutinho index1	1.43 ± 0.78	1.79 ± 0.26	1.30 ± 0.84	0.04

¹Splenectomized patients excluded.

INR: International normalized ratio; APRI: Aspartate-to-platelet ratio index; FIB-4: Fibrosis-4 index; HE: Hepatic encephalopathy.

Table 6 Ultrasonographic characteristics of 200 patients with hepatosplenic schistosomiasis, according to the presence or absence of hepatic encephalopathy diagnosed by Animal naming (Recife, Brazil, 2025)

Variables		Total (%)	With HE, n = 49 (%)	Without HE, n = 151 (%)	P value
Niamey classification	D	22 (11.00)	9 (18.37)	13 (8.61)	0.057
	E	128 (64.00)	25 (51.02)	103 (68.21)
	F	50 (25.00)	15 (30.61)	35 (23.18)
Prior splenectomy		94 (47.00)	21 (42.86)	73 (48.34)	0.61
Portal vein not visualized1		45 (22.50)	6 (12.24)	39 (25.83)	0.074
Longitudinal diameter of spleen (n = 106)		16.15 ± 8.44	16.07 ± 8.50	16.17 ± 8.41	0.89
Portal vein diameter (n = 155)		1.02 ± 0.49	1.03 ± 0.49	1.01 ± 0.49	0.68
Splenic vein diameter (n = 106)		0.97 ± 0.52	0.90 ± 0.53	0.96 ± 0.53	0.57

¹Portal vein thrombosis or cavernoma or technical difficulties.

Data are showed as n (%) or mean ± SD. HE: Hepatic encephalopathy.

Table 7 Comparative analysis of hepatic encephalopathy prevalence across different etiologies of non-cirrhotic portal hypertension

Ref.	Etiology	Country	Sample size	HE prevalence (%)	HE assessment method	Key findings related to PSS
Webb and Sherlock[26], 1979	EHPVO	United Kingdom	76	35.5	Clinical	High HE prevalence but no systematic PSS correlation
Sharma et al[28], 2008	EHPVO	India	22	31.82	Neuropsychological tests, CFF, blood ammonia, MRI	MHE correlates with PSS (72.7% vs 17.4%, P = 0.001)
Mohan and Venkataraman[27], 2011	EHPVO, INCPH	India	46	4.3	A and B track and CFF	No PSS correlation
Nicoletti et al[24], 2016	PVT and INCPH	Italy	51	PVT: 37.1; INCPH: 31.3	West Haven criteria, PHES, and the scan battery	Correlation with PSS in INCPH (71.4% vs 33.3%; P = 0.02)
Riggio et al[31], 2005	Cirrhosis	Italy	12	14	Neuropsychological tests, EEG, blood ammonia, MRI	Correlation with PSS (71% vs 14%; P = 0.002)
Present study	HSS	Brazil	200	24.5	Neuropsychological tests	Strong association between HE and PSS (P = 0.0018)

A and B track test: Attention and coordination tests used for minimal hepatic encephalopathy diagnosis; HE: Hepatic encephalopathy; PSS: Portosystemic shunts; EHPVO: Extrahepatic portal vein obstruction; INCPH: Idiopathic non-cirrhotic portal hypertension; PVT: Portal vein thrombosis; CFF: Critical flicker frequency; MRI: Magnetic resonance imaging; MHE: Minimal hepatic encephalopathy; PHES: Psychometric Hepatic Encephalopathy Score; EEG: Electroencephalogram.