Elevated alkaline phosphatase

Elevated alkaline phosphatase
Micrograph showing changes that may be associated with an elevated alkaline phosphatase (cholestasis and feathery degeneration). Liver biopsy. H&E stain.
Classification and external resources
Specialty	Pathology
ICD-10	R74.8
ICD-9-CM	790.5

Elevated alkaline phosphatase describes the situation where the levels of alkaline phosphatase exceed the reference range. It can be associated with certain medical conditions^[1] or syndromes (e.g., hyperphosphatasia with mental retardation syndrome, HPMRS)

If the reason alkaline phosphatase is elevated is not known, isoenzyme studies using electrophoresis can confirm the source of the ALP. Heat stability also distinguishes bone and liver isoenzymes ("bone burns, liver lasts").

Liver

• Liver (liver ALP):
  • Cholestasis, cholecystitis, cholangitis, cirrhosis, primary biliary cirrhosis, fatty liver, sarcoidosis, liver tumor, liver metastases, drug intoxication
  • Drugs: e.g. verapamil, carbamazepine, phenytoin, erythromycin, allopurinol, ranitidine

Bone/skeletal

• Bone disease (bone ALP):
  • Paget's disease,^[2] osteosarcoma, bone metastases of prostatic cancer (High / very high ALP values)
  • Other bone metastases
  • Renal osteodystrophy
  • Fractured bone
  • Multiple myeloma (only when associated with fractures)
• Skeletal involvement of other primary diseases:
  • Osteomalacia, rickets, vitamin D deficiency (moderate rise)
  • Malignant tumors (ALP originating from tumor)
  • Renal disease (secondary hyperparathyroidism)
  • Primary hypothyroidism

Other unlisted musculoskeletal conditions may also cause elevated alkaline phosphatase.

Cancer

As carcinoplacental alkaline phosphatase (Reagan's isoenzyme)

• Breast carcinoma
• Colon cancer

Other

• Lung cancer
• Prostate cancer
• Chlorpropamide therapy
• Infectious mononucleosis
• Pancreatic carcinoma
• Primary sclerosing cholangitis
• Polycythemia vera
• Myelofibrosis
• Leukemoid reaction to infection
• Women using hormonal contraception
• Pregnancy
• Herpes zoster (shingles)
• Rickets - vitamin D deficiency
• Amyloidosis
• Granulation tissue
• Gastrointestinal inflammation - inflammatory bowel disease (ulcerative colitis, Crohn’s disease) or ulcers)
• Rheumatoid arthritis
• Ankylosing Spondylitis
• Transient hyperphosphatasaemia of infancy: benign, often associated with infection
• Seminoma^[3]
• Hyperthyroidism^[4]
• Celiac disease ^[5]
• Sarcoid^[6]
• Syphilis^[7]

References

1. Li-Fern H, Rajasoorya C (February 1999). "The elevated serum alkaline phosphatase--the chase that led to two endocrinopathies and one possible unifying diagnosis". Eur. J. Endocrinol. 140 (2): 143–7. doi:10.1530/eje.0.1400143. PMID 10069658.
2. Gennari L, Di Stefano M, Merlotti D, et al. (October 2005). "Prevalence of Paget's disease of bone in Italy". J. Bone Miner. Res. 20 (10): 1845–50. doi:10.1359/JBMR.050518. PMID 16160742.
3. Lange PH, Millan JL, Stigbrand T, Vessella RL, Ruoslahti E, Fishman WH (August 1982). "Placental alkaline phosphatase as a tumor marker for seminoma". Cancer Res. 42 (8): 3244–7. PMID 7093962.
4. L Tibi, A W Patrick, P Leslie, A D Toft and A F Smith (1989-07-01). "Alkaline phosphatase isoenzymes in plasma in hyperthyroidism". Clinchem.org. Retrieved 2014-07-03.
5. Pruessner, Harold T, “Detecting Celiac Disease in your Patients” American Family Physician: 57 (5), March 1, 1998 pp1023-1034.
6. Eur J Gastroenterol Hepatol. 2012 Jan;24(1):17-24. doi: 10.1097/MEG.0b013e32834c7b71. Liver-test abnormalities in sarcoidosis. Cremers J, Drent M, Driessen A, Nieman F, Wijnen P, Baughman R, Koek G.
7. Pareek, S. S., “Liver involvement in secondary syphilis” Digestive Diseases and Sciences: 24 (1), January 1979 pp41-43.

External links

• Alkaline phosphatase at Lab Tests Online