American Indians and Alaska Natives (AI/ANs) die from chronic liver disease at high rates, but little data exist on the etiology of liver disease in AI/ANs. Adult participants from a tribal health clinic in the Pacific Northwest completed an alcohol consumption survey and underwent laboratory testing, and anthropometric measurements. Participants with abnormal serum alanine aminotransferase (ALT) levels, positive hepatitis B surface antigen, or hepatitis C antibody were invited for follow-up visit. Then, they received a limited liver ultrasound, additional liver function tests, and confirmatory hepatitis tests. Among 71 participants, 26 (37%) had sustained elevation of ALT over six months. Two patients (8%) had chronic hepatitis C virus and 19 (73%) had ultrasonographic steatosis suggesting nonalcoholic fatty liver disease (NAFLD). Elevated aminotransferase levels were common, with NAFLD and hepatitis C accounting for most cases. Few participants were aware of their liver condition, indicating the need for increased awareness, screening, and intervention.