• Zita Galvin, Anna McDonough, John Ryan, and Stephen Stewart.
• Centre for Liver Diseases, Mater Misericordiae University Hospital, Dublin, Ireland zitagalvin@gmail.com.
• Clin Med. 2015 Jun 1; 15 (3): 244247244-7.

AbstractStandard medical education dictates that the vast majority of cases of an alanine aminotransferase (ALT) level >1,000 IU/l will be due to acute ischaemia, acute drug-induced liver injury (DILI) (usually paracetamol) or acute viral hepatitis. There are very few references in the literature to other potential causes of an ALT >1,000 IU/l nor to the prognosis ascribed to each aetiology. In this study, we have confirmed that the main causes of a dramatic ALT rise are ischaemic liver injury, DILI and viral hepatitis. Common bile duct stones and hepatitis E are two causes for which there needs to be a high index of suspicion as the necessary tests may not be in the clinician's first-line investigation panel. Failing to find a cause and determining that the cause was ischaemic both have poor prognostic implications.© Royal College of Physicians 2015. All rights reserved.

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