Searching for more common competing diagnoses of liver
injury based upon the laboratory profile at presentation is
also important. Hepatocellular injuries prompt suspicions of viral hepatitis, ischemia, and autoimmune hepatitis. A detailed
alcohol history is critical when the transaminase
pattern (modest elevation; aspartate aminotransferase [AST]
> 2x ALT) is consistent with alcoholic hepatitis. A rapid rise
and fall of serum aminotransaminase levels are hallmarks for
ischemic injury. Autoimmune hepatitis (AIH) is often one of
the more difficult competing diagnosis to eliminate because
like DILI there is no single objective diagnostic test for AIH.54
Budd-Chiari syndrome can also present with acute hepatocellular
injury and should be pursued with appropriate
imaging studies (e.g., Doppler ultrasound, computed tomography
or magnetic resonance imaging).