When liver disease starts affecting the mind

A son once told us his father had become “very stubborn and forgetful lately”. The father had cirrhosis. What he actually had was hepatic encephalopathy, and it had been going on for close to three weeks before anyone connected it to the liver.

This is the complication families miss most, because it does not look like a liver problem at all. It looks like old age, like mood, like tiredness.

Why the liver affects the brain

One of the liver's jobs is to clean the blood of waste products that the gut produces every day, ammonia among them. When the liver is badly scarred, two things happen — it cannot clean properly, and blood starts bypassing it altogether through side channels.

Those waste products then reach the brain. The brain does not get damaged in the way a stroke damages it. It slows down. And because it slows down rather than breaks, it can speed back up again once the cause is treated. That is the most important thing to understand about this condition: in most cases it is reversible.

What families notice first

The early signs are quiet. They are almost always put down to something else.

• Day and night get reversed — sleeping through the afternoon, awake and restless at 2 am. This is very often the first sign
• Forgetting recent things, asking the same question again after a few minutes
• Irritability, or saying things that do not quite make sense
• Handwriting becoming shaky or untidy compared to a month ago
• Taking a long time to answer a simple question
• The hands flapping when the arms are held out straight, like a bird's wings

If you hold the person's arms out in front of them with the palms facing forward and the wrists bent back, and the hands begin to flap, that is worth getting checked this week. It is one of the few signs of this condition you can look for at home.

What sets it off

An episode usually has a trigger, and finding the trigger is most of the treatment.

• Constipation — the commonest one by a distance
• An infection anywhere, including the urine or the fluid in the abdomen
• Bleeding in the stomach or food pipe
• Dehydration from vomiting, loose motions, or water tablets
• Sleeping tablets and sedatives
• Alcohol

One thing families get wrong

Many families stop giving dal, egg, milk and paneer the moment the word “liver” is mentioned, because somebody told them protein is harmful. This was the advice decades ago and it has been reversed.

A patient with cirrhosis who is kept off protein becomes weak and loses muscle, and losing muscle makes this condition worse, not better. Unless you have specifically been told otherwise for a reason, the person needs protein, spread through the day, and something small at bedtime.

How serious it is

• Mild — only the family notices, and usually only in hindsight
• Moderate — confused about the date, the place, or the people around them
• Severe — very drowsy, difficult to wake, or not responding. This one needs a hospital the same day, not an appointment

The mild stage is where it should be caught. By the time it reaches the severe stage, an admission is usually unavoidable.

Once it has happened

A first episode means the liver has reached a stage where this will probably happen again unless two things are handled: the trigger each time, and the state of the liver underneath. Many patients go years without a second episode once both are managed properly.