Traditional aqueous kava extracts were the most probable cause of hepatitis in two patients presenting with markedly elevated transaminases and hyperbilirubinaemia. A consequent survey of 27 heavy kava drinkers in New Caledonia showed elevated gamma glutamyl transferase in 23/27 and minimally elevated transaminases in 8/27. We conclude that not only commercially available, but also traditionally prepared kava extracts may rarely cause liver injury. The increased activity of gamma glutamyl transferase in heavy kava consumers in the presence of normal or minimally elevated transaminases is probably not a sign of liver injury, but rather reflects an induction of CYP450 enzymes.