A confusing picture: Refractory encephalopathy complicating non-alcoholic steatohepatitis

A 72-year-old veteran with a past medical history of non-alcoholic steatohepatitis with compensated cirrhosis, history of grade 1 esophageal varices managed medically, diabetes mellitus, and coronary artery disease, presented to the emergency department with increasing confusion. He had been seen by his primary care provider one week prior to the onset of symptoms without any complaints and had been working on his roof to clean out the gutters 4 days prior to presentation. Per the family, the patient began to perseverate on his computer and became progressively less interactive with his family over the 3 days prior to presentation.