Introduction Liver failure + ecephalopathy onset < 8 weeks post hepatic dysfunction Caused by Reye syndrome Drugs acetaminophen methamphetamine heavy alcohol use infection (e.g. viral hepatitis) 0.1-0.5% of patients with hepatitis B develop In 15-25% of pregnant women with hepatitis E infection can be seens with Hep B and D coinfection Presentation Symptoms vomiting stupor coma death Physical exam jaundice not typically seen in Reye's hepatomegaly Evaluation Labs ↑ or normal transaminases depends on the cause acidosis pH < 7.3 ↑ PT time due to ↓ synthesis of clotting factors from liver coagulopathy always present INR > 6.5 ↑ ammonia / azotemia poor functioning of urea cycle in failing liver Treatment Manage labs correct coagulation, acid/base, electrolyte, glycemic disturbances Manitol if cerebral edema present Liver transplant