A Confusing Picture: Refractory Encephalopathy Complicating Nonalcoholic Steatohepatitis

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