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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)