Shaw Jawaid, Bajaj Jasmohan S
*Department of Medicine, McGuire VA Medical Center †Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA.
J Clin Gastroenterol. 2017 Feb;51(2):118-126. doi: 10.1097/MCG.0000000000000764.
Liver cirrhosis is a public health problem and hepatic encephalopathy is one of its main complications, which can be either overt meaning thereby evident and readily diagnosed, or covert/minimal (covert hepatic encephalopathy-CHE) needing psychometric testing for diagnosis. Patients with CHE hepatic encephalopathy have deficits in multiple domains including visuospatial assessment, attention, response inhibition, working memory, along with psychomotor speed to name a few areas. These patients have poor navigational skills, get fatigued easily, and demonstrate poor insight into their driving deficits. The combination of all these leads them to have poor driving skills leading to traffic violations and crashes as demonstrated not only on the simulation testing but also in real-life driving events. There are multiple psychometric tests for CHE testing but these are not easily available and there is no uniform consensus on the gold standard testing as of yet. It does not automatically connote that all patients who test positive on driving simulation testing are unfit to drive. The physicians are encouraged to take driving history from the patient and the caregivers on every encounter and focus their counseling efforts more on patients with recent history of traffic crashes, with abnormal simulation studies and history of alcohol cessation within last year. As physicians are not trained to determine fitness to drive, their approach toward CHE patients in regards to driving restrictions should be driven by ethical principles while as respecting the local laws.
肝硬化是一个公共卫生问题，肝性脑病是其主要并发症之一，肝性脑病可分为显性（即明显且易于诊断）或隐性/轻微型（隐性肝性脑病-CHE），后者需要进行心理测量测试来诊断。患有CHE肝性脑病的患者在多个领域存在缺陷，包括视觉空间评估、注意力、反应抑制、工作记忆以及心理运动速度等。这些患者的导航技能较差，容易疲劳，并且对自己的驾驶缺陷缺乏洞察力。所有这些因素综合起来导致他们的驾驶技能不佳，不仅在模拟测试中，而且在现实驾驶事件中都表现出交通违规和撞车事故。有多种用于CHE测试的心理测量测试，但这些测试并不容易获得，而且目前对于金标准测试尚无统一共识。这并不意味着所有在驾驶模拟测试中呈阳性的患者都不适合驾驶。鼓励医生在每次接诊时询问患者及其护理人员的驾驶史，并将咨询重点更多地放在近期有交通事故史、模拟研究异常以及去年有戒酒史的患者身上。由于医生没有接受过确定驾驶适宜性的培训，他们在对待CHE患者的驾驶限制问题时，应遵循道德原则并尊重当地法律。
