Differential Diagnosis for Acute Elevation in ALT greater than AST with Normal ALP and GGT

Single Most Likely Diagnosis

• Viral Hepatitis: This is the most common cause of acute elevation in ALT greater than AST. Viral hepatitis, such as hepatitis A, B, or C, typically presents with a significant increase in ALT levels compared to AST, and normal levels of ALP and GGT.

Other Likely Diagnoses

• Acetaminophen Toxicity: Overdose of acetaminophen can cause a significant elevation in ALT levels, often with a minimal increase in AST. Early recognition and treatment are crucial to prevent liver failure.
• Alcoholic Liver Disease (Early Stage): Although AST is typically elevated more than ALT in alcoholic liver disease, in the early stages, the pattern can be reversed. However, this would be less likely given the normal GGT.
• Non-Alcoholic Fatty Liver Disease (NAFLD): While NAFLD usually presents with a mild elevation in liver enzymes, in some cases, especially with significant steatohepatitis, ALT can be elevated more than AST.

Do Not Miss Diagnoses

• Wilson's Disease: A genetic disorder leading to copper accumulation in the liver. It can present with acute liver failure and a pattern of liver enzyme elevation similar to viral hepatitis. Missing this diagnosis can be fatal.
• Autoimmune Hepatitis: Although it more commonly presents with a chronic course, autoimmune hepatitis can have an acute presentation with significantly elevated liver enzymes, including ALT greater than AST.
• Budd-Chiari Syndrome: Obstruction of the hepatic veins can lead to acute liver injury with elevated liver enzymes. It's a rare but potentially life-threatening condition if not recognized and treated promptly.

Rare Diagnoses

• Alpha-1 Antitrypsin Deficiency: A genetic disorder that can cause liver disease due to the accumulation of abnormal alpha-1 antitrypsin protein in hepatocytes. It can present with elevated liver enzymes, including ALT greater than AST.
• Hemochromatosis: Genetic iron overload can lead to liver injury and elevation in liver enzymes, though it typically presents with other signs of iron overload and would not be a first consideration without additional context.
• Drug-Induced Liver Injury (DILI): Various medications and herbal supplements can cause liver injury with a pattern of ALT elevation greater than AST. The history of medication or supplement use is crucial for diagnosis.