Alkaline Phosphatase Elevation

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)
2.  If 5´-NT / GGT are elevated, the ↑ Alk. Phos. is due to liver disease
  • 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.)
 3.  For ↑ Alk. Phos. due to Liver disease, order:
  • Abdominal (or RUQ) Ultrasound for biliary tract disorders
  • Anti-Mitochondrial Antibody (AMA) for Primary Biliary Cirrhosis (PBC)
  • RPR / VDRL for 2° Syphilis
 4.  Results:
  • 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
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