A 34-year-old woman presents to the emergency department with a 1 week history of fatigue, malaise, lethargy and jaundice. Her initial examination shows she is disoriented and has asterixis in keeping with suspected hepatic encephalopathy. The lab tests show an AST of 15,070 IU/L, ALT 22,000 IU/L, INR 5.4, Bilirubin of 23 mg/dL (393 micromol/L).