Transaminitis (DDx in Marked Elevation)

Differential Diagnosis for Severe Transaminitis in the 1000s
While LFTs in the 100s range is fairly common, the the DDx of AST/ALT > 1000 is narrow.  The 3 most common causes are:

1)  Ischemic Hepatitis
2)  Acute Viral Hepatitis (HAV, HBV, NOT HCV)
3)  Drug/Toxin Induced Liver Injury – by far the most common being Tylenol

**Of note, alcoholic hepatitis does not cause AST/ALT rises > 500!! **
Clues that favor ischemic hepatitis over the other viral or drug-injury:

• Markedly elevated LDH – fairly specific for ischemic hepatitis
• Rapid fall in AST/ALT after initial insult (in viral or drug-induced liver injury, LFTs take weeks to months to normalize)
• Other signs of shock or end-organ perfusion, especially renal failure

Other, less common causes of LFTs in the 1000s include:

• Exacerbation of Autoimmune Hepatitis
• Acute Budd Chiari, especially with concomitant portal vein thrombosis
• HELLP, Acute Fatty Liver of Pregnancy
• Hepatic Infarction
• Reactivation of chronic Hep B, or Hepatitis D superimposed on chronic Hep B
• Wilsonian Crisis – presents with acute liver failure in young adults/children, with concomitant hemolytic anemia.

(Chanu Rhee MD, 5/23/11)