Alkaline Phosphatase (ALP)

Gamma- glutamyl
transpeptidase (GGT)
Name: Razeen Riyasat Ali
ID: 20180014
Alkaline Phosphatase (ALP)

• Normal Value: 30-130 units/L

• Where is it present?
- Liver (Predominantly)
- Bones
- Placenta -> During Pregnancy
How will you know that elevated ALP is due
to liver pathology or bone disease?
• Measure Gamma-Glutamyl Transferase (GGT) or serum 5’-
nucleotidase levels.
• If ALP is elevated + elevation of GGT and/or 5’-nucleotidase = Liver
pathology
• If ALP elevated + ”NO” elevation of GGT and/or 5’-nucleotidase =
Bone pathology
What is the Differential Diagnosis if there is
elevated ALP of hepatic origin?
• Chronic cholestasis, the most common include bile duct obstruction,
Primary Biliary Cholangitis (PBC), Primary Sclerosing cholangitis,
certain drugs such as phenytoin
• Infiltrative disease such as sarcoidosis or amyloidosis
How will you elevaluate elevated ALP of
hepatic origin?
• Evaluation starts with RUQ ultrasonography to access hepatic
parenchyma and bile ducts.
• Biliary dilation -> Suggests extrahepatic cholestasis
• Absense of biliary dilation -> suggests intrahepatic cholestasis
• Extra-hepatic cholestasis causes include:
• Choledocholithiasis – Most common
• Malignant obstruction
• Primary Sclerosing cholangitis with extrahepatic bile duct stricture
• Chronic pancreatitis with stricturing at the distal bile duct
What to do next in extra-hepatic Chlestasis?
• If ultrasound suggests obstruction due to stone or malignancy then
use endoscopic retrograde cholangiopancreatography (ERCP) to
confirm the diagnosis and facilitate biliary drainage
• Magnetic resonance cholangiopancreatography (MRCP) can also be
used instead of ERCP
• If MRCP or ERCP is negative for biliary tract disease then liver biopsy
should be considered.
What to do next if the elevation of ALP is due
to intrahepatic cholestasis?
• There are numerous causes for intrahepatic cholestasis. A px history
can be used to identify the cause. If no cause is idenified then the
following tests are required:
• Anti-mitochondrial antibodies- suggests Primary Biliary cholangitis (PBC)
• Test for hepatitis A,B,C and E
• Test for EBV and cytomegalovirus
• Pregnancy testing in woman of child bearing age who is not known to be
pregnant.
Gamma- Glutamyl Transpeptidase (GGT)
• Normal Values:
> Males: 8-61 units/L
> Females: 5-36 units/L
• Elevation of GGT is seen in:
> Liver Disease
> Pancreatic Disease
> MI
> DM
> Renal Failure
> Medications such as phenytoin and barbiturates
• The usefulness of GGT is limited by its lack of specificity.
• An isolated GGT elevation in the presence of normal liver should NOT lead to exhaustive workup for liver
disease
Reference
• Friedman, L., 2021. Approach to the patient with abnormal liver
biochemical and function tests. [online] Www-uptodate-
com.unifiji.idm.oclc.org. Available at: <https://www-uptodate-
com.unifiji.idm.oclc.org/contents/approach-to-the-patient-with-
abnormal-liver-biochemical-and-function-tests?search=liver
%20function
%20test&source=search_result&selectedTitle=1~150&usage_type=de
fault&display_rank=1#H150965033> [Accessed 26 July 2021].