Patients suffering HE may come to the doctor with a whole lot of symptoms. In mild cases, called minimal HE, the patient may have no symptoms but have cognitive problems revealed by formal neuropsychiatric testing (e.g., number connection tests, etc.). With more advanced HE, fatigue, and at least mild problems of memory, concentration, and coordination may become apparent. At this stage, common complaints by the patient include:
“I feel like my head is in the clouds.”
“I’ll walk into a room and forget why I am there.”
“I am always tired…but I can’t sleep.”
“I often forget what to say in mid-sentence.”
“My boss is telling me that my work is slipping.”
“My handwriting has changed to scribble.”
"My hands shake so much; I can’t hold my coffee cup without spilling it.”
Nighttime insomnia is a very common and troublesome symptom associated with HE. In fact, patients with HE may ultimately sleep more during the day, with fitful naps, than at night, and this “day-night reversal” is a hallmark of more advanced HE. Family and friends frequently notice a deterioration of the patient’s cognitive function as well as a change in the patient’s personality—with frequent irritability, bouts of anger, and loss of social graces. They may also witness firsthand deterioration of the patient’s driving skills (“He would have run off the road if I hadn’t grabbed the wheel!” or “He was driving home from work, a path he has taken for many years, and got lost for 2 hours!”).
Two of the most common physical (as opposed to subjective) manifestations of HE are asterixis and fetor hepaticus. Asterixisis a coarse tremor– known colloquially as a “liver flap”–that is best elicited by asking the patient to outstretch the hands with straight elbows, wrists cocked at 90 degrees, and fingers spread apart, instructions easily communicated with the command, “Stop traffic!” Although such a tremor is not specific for HE (it can also be seen with renal failure and other conditions), it certainly suggests the diagnosis in patients with liver disease. Fetor hepaticus is a musty sweet odor that is usually evident by casually sniffing the patient’s breath.
When symptoms of HE progress, the patient may slip into a stupor or even comatose state and be virtually un-arousable. Such situations are medical emergencies, and the patient should be brought to the hospital emergency room immediately.