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©2013 UpToDate ® Print Email Stages of acute acetaminophen intoxication Stage Hours after ingestion Clinical features I 0.5 to 24 hours Nausea, vomiting, diaphoresis, pallor, lethargy, and malaise Some patients remain asymptomatic Laboratory studies are typically normal II 24 to 72 hours Stage I symptoms resolve Hepatotoxicity and nephrotoxicity become evident Right upper quadrant pain, liver enlargement and tenderness Elevation of aminotransferases occurs within 36 hours of ingestion in patients with hepatic injury Elevation of prothrombin time (PT) and internationalized ratio of PT Oliguria, abnormalities of renal function Elevation of serum amylase with or without clinical pancreatitis may occur III 72 to 96 hours Liver enzyme and function abnormalities peak (enzymes may be >10,000 IU/L) Recurrence of Stage I symptoms Jaundice, hepatic encephalopathy, hyperammonemia, bleeding diathesis, hypoglycemia, lactic acidosis Renal failure, the incidence of which is related to the severity of intoxication Death, from multi-organ failure, occurs most commonly in this stage IV 4 to 14 days Recovery phase Symptoms and laboratory values may not normalize for several weeks Histologic recovery lags behind clinical recovery and may take up to three months