Fatal cholestatic jaundice associated with amitriptyline

A 75-year-old woman was admitted with a two-week history of anorexia and va gue abdominal pain. She had been taking amitriptyline 75 mg at night for de pression for four months before her admission. On presentation she was jaun diced, but with no stigmata of chronic liver disease. Initial liver functio n tests showed a slightly raised bilirubin, but were otherwise normal. Over the next three weeks her bilirubin concentration continued to rise without evidence of biliary obstruction on ultrasound examination. Her condition c ontinued to deteriorate, and she later developed renal failure consistent w ith hepatorenal syndrome. Seven weeks after admission she died following a large gastrointestinal bleed. At autopsy, liver histology confirmed pure ch olestasis consistent with amitriptyline ingestion.