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Causes of Elevated Alkaline Phosphatase Cheat Sheet (DRAFT) by [deleted]

Causes of elevated alkaline phosphatase

This is a draft cheat sheet. It is a work in progress and is not finished yet.

Causes of elevated alkaline phosph­atase

Hepato­biliary
Bile duct obstru­ction
 ­ ­ ­  Choled­och­oli­thiasis
 ­ ­ ­  Malignant obstru­ction
 ­ ­ ­  Bile duct flukes
Bile duct stricture
Ductopenia
AIDS cholan­gio­pathy
Choles­tatic liver diseases
 ­ ­ ­  Primary biliary cirrhosis
 ­ ­ ­  PSC
Medica­tions and drug-i­nduced liver injury
Infilt­rative diseases of the liver
 ­ ­ ­  Sarcoid
 ­ ­ ­  Granul­omatous hepatitis
 ­ ­ ­  Tuberc­ulosis
 ­ ­ ­  Amyloid
 ­ ­ ­  Metastatic cancer
 ­ ­ ­  Lymphoma
Hepatic abscess
Hepato­cel­lular carcinoma
Viral hepatitis
Cirrhosis
Vanishing bile duct syndrome
Ischemic cholan­gio­pathy
Benign recurrent choles­tasis
Sarcoi­dosis
Alcoholic liver disease
Intrah­epatic choles­tasis of pregnancy
Benign post-o­per­ative jaundice
ICU jaundice or multif­act­orial jaundice
TPN
Liver allograft rejection
Acute alcoholic hepatitis
Sickle cell liver crisis
Sepsis
Congestive heart failure
Hemoph­ago­cytic lympho­his­tio­cytosis
Non-he­patic
Bone disease
 ­ ­ ­  Osteom­alacia
 ­ ­ ­  Paget’s disease
Primary bony malignancy
Bony metastases
Hypert­hyr­oidism
Hyerpa­rat­hyr­oidism
 

Continued

Pregnancy (third trimester)
Chronic renal failure
Lymphoma
Extra-­hepatic malignancy
Congestive heart failure
Childhood growth
Infection
Inflam­mation
Influx of alkaline phosph­atase after a fatty meal
Blood type O and B
Myeloid metaplasia
Perito­nitis
Diabetes mellitus
Gastric ulcer
Increasing age, especially women
PSC, primary sclerosing cholan­gitis; TPN, total parenteral nutrition.

Algorithm for Evaluation - Normal

Normal total bilirubin & serum transa­minases
1. History & physical exam
confirm with serum GGT
2. If GGT normal --> evaluate for non-he­pat­obi­liary etiologies
If GGT abnormal --> obtain right upper quadrant ultras­ound,
evaluate for potential hepato­toxic medica­tions,
check AMA, ANA, & SMA
3. If evaluation negative & alkaline phosph­atase > 2x ULN -->
consider liver biopsy
If evaluation negative & alkaline phosph­atase 1-2x ULN -> consider
observ­ationIf ductal dilatation identified --> ERCP or MRCP
If AMA positive --> evaluate for primary biliary cirrho­sis­/ch­ola­ngitis
4. f persistent elevation of serum alkaline phosph­atase after
6 months observ­ation --> consider liver biopsy

Algorithm for evaluation - Elevated

Elevated serum transa­minases ± elevated bilirubin
1. History & Physical exam
Check right upper quadrant ultrasound
2. If ductal dilatation --> ERCP, MRCP
If no ductal dilatation --> check AMA, ANA, SMA
3. If AMA positive --> evaluate for primary biliary cirrho­sis­/ch­ola­ngitis
If AMA negative & alkaline phosph­atase > 2x ULN --> consider liver
biopsy or MRCP
If AMA negative & alkaline phosph­atase 1-2x ULN --> consider
observ­ation
4. If persistent elevation of serum alkaline phosph­atase after
6 months observ­ati­on-­-> consider liver biopsy or MRCP