Liver and intrahepatic bile ducts - nontumor
Hepatitis (drug / toxin induced)

Topic Completed: 1 June 2016

Revised: 23 January 2019, last major update June 2016

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PubMed Search: Drug[TI] OR toxin[TI] "induced hepatitis"[TI] full text[sb]

Anthony W.H. Chan, F.R.C.P.A.
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Cite this page: Chan A. Drug / toxin induced hepatitis - general. website. Accessed March 31st, 2020.
Definition / general
  • Drug / toxin reactions can be intrinsic or predictable, where they are dose dependent (e.g. acetaminophen); or idiosyncratic and unpredictable, where they are dose independent (e.g. isoniazid)
  • Underlying mechanisms include direct / indirect toxicity, aberrant metabolism producing toxic metabolites and immune mediated hypersensitivity

  • Risk factors (J Hepatol 2015;63:503)
    • Drug properties (e.g. threshold dosage, lipophilicity, toxic metabolite, oxidative stress, mitochondrial liability, inhibition of hepatobiliary transporters)
    • Host factors (e.g. age, gender, underlying liver or other disease, genetic factors)
    • Drug - host interaction
Diagrams / tables

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Consensus criteria
for terminology
in drug induced
liver injury

Overview of drug induced liver injury patterns

Herbal products with known hepatotoxicity

Clinical features
  • Very wide range of clinical and pathological presentations can result; the time of onset after drug exposure varies from hours to months
  • Clinical manifestations range from asymptomatic deranged liver function to fulminant hepatic failure and death
  • Mimic all forms of acute, chronic, vascular or neoplastic liver diseases that are caused by other etiologies
  • Diagnosis of drug or toxin induced liver injuries requires clinical, biochemical and pathological correlation
  • LiverTox, which is produced by NLM (National Library of Medicine) and NIDDK (National Institute of Diabetes and Digestive and Kidney Disease), provides up to date, accurate and easily accessed information on drug induced liver injury
Microscopic (histologic) description
  • Morphological patterns can be categorized into:
    • Necroinflammatory injury: acute hepatic necrosis, acute hepatitis and granulomatous hepatitis
    • Cholestatic injury: bland cholestasis, acute cholestatic hepatitis and chronic cholestatic injury
    • Steatosis and steatohepatitis
    • Vascular lesion: sinusoidal obstruction syndrome, Budd-Chiari syndrome, nodular regenerative hyperplasia, hepatoportal sclerosis, sinusoidal dilatation and peliosis
    • Neoplasm and neoplasm-like lesion
    • Adaptive change
Microscopic (histologic) images

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Resolving hepatitis

Prolonged cholestasis

Microvesicular steatosis

Sinusoidal obstruction syndrome


Stellate (Ito) cell lipidosis

Ground glass hepatocytes

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