We appreciate the comments of Kountouras et al. regarding our article showing that cognitive dysfunction evaluated by the Psychometric Hepatic Encephalopathy Score (PHES) is associated with falls during follow-up in patients with cirrhosis.1 We agree with these authors that subclinical cognitive dysfunction in cirrhosis is a multifactorial issue. Although minimal hepatic encephalopathy plays a key role in such dysfunction, other factors, such as etiology of cirrhosis, comorbidities, or psychoactive treatments, can also be implicated.1-3 Multiple factors are also involved in the risk of falling.4
Helicobacter pylori infection has been suggested as a factor predisposing patients with cirrhosis to overt hepatic encephalopathy and minimal hepatic encephalopathy through the increase in ammonemia5, 6 or, as proposed by Kountouras et al., through the proinflammatory state. However, this association has not been clearly demonstrated.5 The relationship between H. pylori and dementia in patients without cirrhosis is also controversial.7, 8 To our knowledge, there are no studies evaluating the potential link between falls or fractures and H. pylori infection. In any case, we cannot study the relationship between H. pylori and cognitive dysfunction or falls in our study group because H. pylori infection was not systematically evaluated in all the patients.
As recently pointed out by Butterworth,9 the main contribution of our article is that it shows that psychometric testing can predict the risk of falling in patients with cirrhosis, in addition to its already known ability to detect the risk of overt hepatic encephalopathy, mortality, and traffic accidents.2, 10 This finding could help to establish measures to prevent falls and fractures and their consequences in this population.1, 9
When considering the mechanisms involved in the risk of falling, we found no correlation between the severity of PHES impairment and predisposition to falling. This suggests that the main cause of falling is not cognitive dysfunction per se but a coincident neuromuscular disturbance, such as parkinsonism, cerebellar degeneration, or sarcopenia.1, 9 The precise mechanisms by which patients with cirrhosis and impaired PHES have a higher tendency to fall remain to be determined.