When the Fog Lifts: Overt Hepatic Encephalopathy and NASH

Some mornings, my thoughts feel like puzzle pieces that refuse to fit together. Words I have always known hide somewhere out of reach, and simple tasks—things I used to do without thinking—become confusing or impossible.

The night when everything changed

It all began the night my youngest son had his high school homecoming dance. My husband, Toby, asked me if I wanted to go with him to pick up our son, and I was excited to share in that important family moment. But on the way, something unexpected happened.

I became fixated on buying press-on nails at Walmart—something I never wear. I argued, spent over $300 on things I did not need, and do not remember a single moment of it. Weeks later, when Toby brought the items into the house, I accused him of lying and of having bought them himself. My youngest son told me, "Mom, it appeared like you were drunk that night."

Hearing that broke me in a way I can barely describe. To embarrass my 14-year-old son in public like that was humiliating. I felt like a hole had opened beneath my feet, and I had fallen into it. Until that moment, I had always trusted my mind. I was articulate, factual, and dependable. Now, I did not know if I could trust my own memory or even my own version of events.

The unpredictable rhythm of liver-related brain fog

Looking back, I now understand that night was my first episode of overt hepatic encephalopathy, a serious complication of advanced liver disease that affects the brain. At the time, no one called it that. I only knew something fundamental had shifted.

Life felt like that childhood rhyme I had always remembered: "If she was good, she was very, very good. If she was bad, she was terrible." Hepatic encephalopathy (HE) was turning my days into that rhythm—unpredictable and uncontrollable. I even began falling asleep in seconds, sometimes in the middle of visiting friends. My friend Debbie immediately knew something was wrong and let me rest, giving me a blanket and pillow. My parents and Toby would make sure I was safe and got home without incident.

Losing independence and learning to trust

After that night, I started noticing just how much living with HE and NASH (also known as MASH) was changing my daily life. I had always been the one to create a monthly budget, keep our utilities on, and handle every detail efficiently. I was the kind of person who touched something once and got it done. Suddenly, I was not.

One morning, Toby noticed a dent in the car. My youngest son told him I had hit a ditch while taking him to school. I insisted it was not true, but eventually, I realized I could not even recall how my son had gotten to school, much less how I had gotten back home.

My siblings thought I was paranoid, overly sensitive, or emotional. That judgment stung, but nothing compared to the internal turmoil I felt. From that moment, I learned to trust Toby completely. If he said my speech was slurred or my thinking was off, he took over everything. I no longer drove, walked alone, or made decisions that might put myself or others at risk. He attended my hepatology appointments with me, and my hepatologist began to look to him for guidance on medications and care because labs often did not reflect the full picture of how this cognitive complication of NASH was affecting me.

Managing HE and NASH through lifestyle and nutrition

Managing HE became about more than just medications. I learned that what I ate, how I rested, and how I managed stress directly affected my brain and my liver. For years, people with HE were told to limit protein, especially animal protein, to control ammonia levels. However, limiting protein too much caused its own problems: muscle wasting, low energy, and poor nutrition.

For me, it was not about eliminating protein entirely. I learned that red meat could trigger liver inflammation and raise ammonia levels, so I limited it to lean cuts, once or twice a week. I embraced whole foods and farm-to-table meals; I avoided ultra-processed items and sugary sodas, replacing them with water or iced tea with lemon. I learned to rest when my body told me to and to prioritize counseling and stress management. Awareness, observation, and lifestyle adjustments became my most powerful tools alongside medications.

Understanding the connection: Cirrhosis and brain function

Living with NASH (or MASH) that progresses to cirrhosis carries risks beyond liver damage itself. As the liver becomes scarred, other conditions can develop, such as ascites, portal hypertension, varices, and overt hepatic encephalopathy.¹ HE occurs when toxins, especially ammonia, build up in the bloodstream because the liver can no longer filter them properly. Those toxins affect the brain, leading to changes in thinking, memory, sleep, behavior, and even personality.²

Patients often do not realize their brain is impaired, which can lead to mistakes, misunderstandings, and public embarrassment. Current treatments focus on medications that help eliminate ammonia through bowel movements, combined with careful monitoring, diet, and lifestyle adjustments.

Finding moments of clarity

Despite the challenges, there are moments when the fog lifts and my brain remembers who it belongs to. Those moments of clarity—when words flow, thoughts connect, and I feel like myself again—are reminders that hepatic encephalopathy does not define me.

Living with the neurological symptoms of MASH has taught me how fragile and precious mental clarity is. It has shown me the importance of trusting caregivers like Toby, who notice subtle changes and step in without hesitation. It has taught me the value of proactive planning because each decision can protect my brain, my independence, and my dignity.

HE affects more than just thinking. It touches identity, confidence, relationships, and daily life. But awareness, preparation, and support can help patients preserve as much of themselves as possible. I have learned that self-care is not selfish. If I do not care for myself, there is no "me" left to give.

A path forward with hepatic encephalopathy and NASH

What gives me hope is that conversations about overt hepatic encephalopathy and NASH are finally happening. More patients and caregivers are learning to recognize early signs, seek help sooner, and advocate for themselves. With education, support, and the right care, it is possible to live fully, even with this condition.

And when those moments come when my mind is clear and sharp again, I remember exactly who I am, and I am reminded that my brain still belongs to me.