If the Alkaline Phosphatase is elevated and ALT & AST normal, it’s due to either liver disease, bone disease, intestinal (recent meal), or placental (pregnancy, 2nd & 3rd trimesters)
1. In non-pregnant patient, order fasting labs:- Repeat Alk. Phos. & all LFTs
- 5´-Nucleotidase (5´-NT) OR gamma glutamyl transpeptidase (GGT)
- If normal, & Alk. Phos. still ↑, it’s due to bone disease
- If normal, & Alk. Phos. now normal, prior ↑ was due to non-fasting specimen (intestinal Alk. Phos.)
- Abdominal (or RUQ) Ultrasound for biliary tract disorders
- Anti-Mitochondrial Antibody (AMA) for Primary Biliary Cirrhosis (PBC)
- RPR / VDRL for 2° Syphilis
- Dilated bile ducts on Ultrasound: send to GI for ERCP to R/O stone or mass
- AMA Positive: Discuss w/ Hepatology re Biopsy vs empiric Tx for PBC
- RPR / VDRL & confirmatory testing both Positive: Tx 2° Syphilis
- All Normal: Work-up Chronic Hepatitis as discussed, follow labs, refer to Hepatology if Alk. Phos. does not trend down