From the Guidelines
Elevated alkaline phosphatase (ALP) and liver enzymes without abdominal pain could have several causes, and the initial evaluation should include a comprehensive history and laboratory tests to determine the underlying etiology. The most recent and highest quality study 1 suggests that the pattern of enzyme elevation (hepatocellular vs. cholestatic) can help narrow the differential diagnosis, with predominant ALP elevation suggesting biliary issues while predominant transaminase elevation suggests hepatocellular injury. Some possible causes of elevated ALP and liver enzymes without abdominal pain include:
- Medication effects
- Alcohol use
- Viral hepatitis
- Autoimmune hepatitis
- Non-alcoholic fatty liver disease
- Biliary obstruction Initial laboratory tests to order include:
- Complete hepatic panel (if not already done)
- Hepatitis serologies (A, B, C)
- Autoimmune markers (ANA, anti-smooth muscle antibody, anti-mitochondrial antibody)
- Iron studies
- Ceruloplasmin (to rule out Wilson's disease)
- Alpha-1 antitrypsin levels Imaging studies should include:
- Abdominal ultrasound to evaluate for biliary obstruction, fatty infiltration, or mass lesions
- Magnetic resonance cholangiopancreatography (MRCP) if ultrasound is inconclusive and cholestasis is suspected, as recommended by 1 It is essential to avoid hepatotoxic medications and alcohol while the evaluation is ongoing, as suggested by 1. The absence of abdominal pain does not rule out serious liver pathology, as many liver conditions are asymptomatic until advanced stages. A comprehensive history focusing on medication use, alcohol consumption, and risk factors for viral hepatitis is crucial in determining the underlying cause of elevated ALP and liver enzymes. In addition to laboratory tests and imaging studies, a review of the patient's clinical history and medications is necessary to determine the etiology of elevated ALP and liver enzymes, as suggested by 1.
From the Research
Causes of Elevated Alk Phos and Liver Enzymes
- Choledocholithiasis: a condition where a stone is present in the common bile duct, can cause elevated liver enzymes and alkaline phosphatase levels, even in the absence of abdominal pain 2
- Congestive hepatopathy: a condition where heart failure leads to liver dysfunction, can cause significantly elevated alkaline phosphatase levels 3
- Defective elimination of alkaline phosphatase: a rare condition where the body is unable to properly eliminate alkaline phosphatase, can lead to unexplained elevations of serum ALP 4
- Other causes: hepatocellular pattern causes (non-alcoholic fatty liver disease, alcohol use, chronic viral hepatitis, etc.) and cholestatic pattern causes (biliary pathology, autoimmune conditions, etc.) can also lead to elevated liver enzymes and alkaline phosphatase levels 5
Diagnostic Approach
- Laboratory investigations: liver chemistry tests, viral hepatitis serology tests, autoimmune serology tests, etc. can help identify the underlying cause of elevated liver enzymes and alkaline phosphatase levels 6, 2
- Imaging studies: abdominal ultrasound, liver biopsy, endoscopic retrograde cholangiopancreatogram, etc. can help diagnose conditions such as choledocholithiasis and congestive hepatopathy 6, 2, 3
- Physical examination and medical history: a thorough physical examination and medical history can help identify symptoms and risk factors associated with elevated liver enzymes and alkaline phosphatase levels 6, 2, 3
Tests to Order
- Liver chemistry tests: to evaluate liver function and identify patterns of liver enzyme elevation 5
- Viral hepatitis serology tests: to diagnose viral hepatitis 6, 2
- Autoimmune serology tests: to diagnose autoimmune conditions such as autoimmune hepatitis 6, 2
- Imaging studies: to diagnose conditions such as choledocholithiasis and congestive hepatopathy 6, 2, 3
- Endoscopic retrograde cholangiopancreatogram: to diagnose and treat choledocholithiasis 6, 2