Symptoms:

Symptoms many begin slowly and gradually worsen, or they may begin suddenly and be severe from the start.

Symptoms may be mild at first. Family members or caregivers may notice that the patient has:

• Breath with a musty or sweet odor
• Change in sleep patterns
• Changes in thinking
• Confusion that is mild
• Forgetfulness
• Mental fogginess
• Personality or mood changes
• Poor concentration
• Poor judgment
• Worsening of handwriting or loss of other small hand movements

More severe symptoms may include:

• Abnormal movements or shaking of hands or arms
• Agitation, excitement, or seizures (occur rarely)
• Disorientation
• Drowsiness or confusion
• Inappropriate behavior or severe personality changes
• Slurred speech
• Slowed or sluggish movement

Patients with hepatic encephalopathy can become unconscious, unresponsive, and possibly enter a coma.

Patients with hepatic encephalopathy are often not able to care for themselves because of these symptoms.

Signs and tests:

Nervous system signs may change. Signs include:

• Coarse, "flapping" shaking of the hands when attempting to hold the arms out in front of the body and lift the hands
• Abnormal mental status, particularly cognitive (thinking) tasks such as connecting numbers with lines
• Signs of liver disease, such as yellow skin and eyes (jaundice) and fluid collection in the abdomen (ascites), and occasionally a musty odor to the breath and urine

Tests may include:

• Complete blood count or hematocrit to check for anemia
• CT scan of the head or MRI
• EEG
• Liver function tests
• Prothrombin time
• Serum ammonia levels
• Sodium level in the blood
• Potassium level in the blood
• BUN and creatinine to see how the kidneys are working