Acute severe elevation in ALT AST

(>1000)

• Massive elevations (>5000) usually due to ischemic injury or drug-induced hepatitis

• Ischemia: hypotension, shock or severe HF (often >50× ULN), Budd-Chiari: usually diagnosed based on clinical hx, U/S w/ Doppler; ratio ALT:LDH <1.5 if ischemic because of concomitant ↑ LDH (vs. ratio >1.5 w/ toxins, viruses)

• Meds/toxins: acetaminophen, meds (eg, INH, amio, nitrofuratonin), OTC/herbal, cocaine (nb, EtOH should not produce this degree of elevation). Obtain acet. level, tox screen.

• Acute viral infection: hepatitis A–E or reactivation of HBV, EBV/CMV

• Acute autoimmune hepatitis (qv): ✓ IgG, ANA, ASMA

• Acute biliary obstruction (often with sig drop in ALT/AST the next day, Aϕ takes longer to rise & fall): start w/ liver U/S, if unrevealing obtain CT or MRCP

• Rhabdomyolysis and heat stroke