A 73-year-old Asian gentleman was admitted via the Accident and Emergency Department with upper abdominal pain, jaundice, fever and rigors. Past history included non-insulin dependant diabetes, asthma, psoriasis and alcoholism. His drug history included methotrexate. A diagnosis of acute cholecystitis was made and ultrasound findings were consistent with this. The patient started to improve but on day 8 of his admission he suddenly deteriorated and arrested. The post mortem revealed complete hepatic necrosis as an unexpected cause of death. There are a number of factors which may be contributory in this case. The fact that our patient expired so rapidly with complete hepatic necrosis was not in keeping with the typical chronic course one might expect. We should always bear in mind the potential for fatal hepatic injury in patients presenting with hepatobiliary symptoms with a past history of alcohol abuse and methotrexate therapy.