A 75-year-old woman was admitted with a two-week history of anorexia and vague abdominal pain. She had been taking amitriptyline 75 mg at night for depression for four months before her admission. On presentation she was jaundiced, but with no stigmata of chronic liver disease. Initial liver function 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 continued to deteriorate, and she later developed renal failure consistent with hepatorenal syndrome. Seven weeks after admission she died following a large gastrointestinal bleed. At autopsy, liver histology confirmed pure cholestasis consistent with amitriptyline ingestion.