Routine laboratory testing is performed quite frequently in the hospital for both diagnostic purposes in symptomatic patients as well as for screening purposes in asymptomatic patients. Many of these screening tests now include serum alkaline phosphatase; although this enzyme is present in tissues throughout the body, it is most often elevated in patients with liver and bone disease. This frequent testing has resulted in a dramatic increase in the number of normal and abnormal chemistry test results that must be evaluated by physicians. Another way of putting this is that 1 out of every 20 tests ordered may be abnormal for the reference range but normal for the measured population. It is important to emphasize that false positive results are more likely in patients who have a low pretest probability of having disease.
You might have a localized itch, such as eoevated your lower arm, or it might be an all-over itch. Treatment of itch. Pruritus out of proportion to appearance of dermatitis. Laboratory, radiographic and other tests that are likely to be useful akl diagnosing the cause of this problem. ALP is an enzyme found throughout the body, but it is mostly found in the liver, bones, kidneys, Itching elevated alk digestive system. Skeletal examination may reveal bony tenderness or deformities. Ensure a non-genetic cause from Itching elevated alk history: There are reports of a Monacan red wing familial elevation in serum alkaline phosphatase levels because of increased levels of intestinal alkaline phosphatase. Here's five changes you may see or feel just by taking more….
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Isoenzymes are a collection of enzymes that catalyze the same chemical reaction but possess different structures and biochemical properties. In order to provide high-quality, cost-effective fiscal and nonfiscal health care, a rational approach for the appropriate evaluation of elevated serum alkaline phosphatase is essential for all practicing physicians. Trending Recommended. This type occurs when you have an underlying condition that causes your calcium levels to be abnormally low. Open Next post in Hospital Medicine Close. Hence, elevated serum alkaline phosphatase activity Itching elevated alk be a marker for inflammation because of its association with elevated levels of CRP. Dons naughty models freesite could Itching elevated alk due to a tumor, gland enlargement, or other structural problems of the parathyroid glands. Along with elevated alkaline phosphatase levels, common signs and symptoms associated with biliary obstruction include upper right side Itching elevated alk pain, dark urine, fever, itching, jaundice or yellowing of your skin, pale-colored stools and nausea and vomiting. Journal of Pakistan Medical Association. If treatment is necessary, surgery is the commonly used treatment. What is the differential diagnosis for this problem? Liver cirrhosis, a progressive condition of your liver, can cause high levels of alkaline phosphatase in your blood.
Patient information: See related handout on pruritus , written by the authors of this article.
- Routine laboratory testing is performed quite frequently in the hospital for both diagnostic purposes in symptomatic patients as well as for screening purposes in asymptomatic patients.
- Martin Hughes is a chiropractic physician, health writer and the co-owner of a website devoted to natural footgear.
- Alkaline phosphatase is naturally found in various tissues in the body.
- Hyperparathyroidism occurs when the parathyroid glands make too much parathyroid hormone PTH.
- Perkins also has extensive experience working in home health with medically fragile pediatric patients.
- But, alkaline phosphatase is more prominent in the liver.
Routine laboratory testing is performed quite frequently in the hospital for both diagnostic purposes in symptomatic patients as well as for screening purposes in asymptomatic patients. Many of these screening tests now include serum alkaline phosphatase; although this enzyme is present in tissues throughout the body, it is most often elevated in patients with liver and bone disease.
This frequent testing has resulted in a dramatic increase in the number of normal and abnormal chemistry test results that must be evaluated by physicians. Another way of putting this is that 1 out of every 20 tests ordered may be abnormal for the reference range but normal for the measured population. It is important to emphasize that false positive results are more likely in patients who have a low pretest probability of having disease.
Alkaline phosphatases are a group of zinc metalloenzymes that catalyze the hydrolysis of phosphate esters with widespread tissue distribution. As the name implies, this enzyme works best at an alkaline pH, and thus the enzyme is virtually inactive in the blood.
Alkaline phosphatases act by splitting off phosphorous, creating an alkaline environment. The origin of serum alkaline phosphatase has interested many workers ever since H. Kay and W. Roberts demonstrated that increased serum activity was found in certain bone and hepatobiliary disorders. It has long been realized that serum alkaline phosphatase arises from tissues rich in the enzyme, and the origin of this enzyme is intricately bound up with that of the mechanisms by which the serum activity is increased in health and in disease.
In order to provide high-quality, cost-effective fiscal and nonfiscal health care, a rational approach for the appropriate evaluation of elevated serum alkaline phosphatase is essential for all practicing physicians.
The interpretation of all medical tests should be performed within the clinical context of the patient. Alkaline phosphatase is distributed widely throughout the body, and normally is plentiful in hepatic parenchyma, osteoblasts, intestinal mucosa, placental cells, and renal epithelium.
Although the primary importance for measuring alkaline phosphatase is to check for the possibility of bone disease or liver disease, forming a differential diagnosis should focus on the pathology see below for causes of normal, physiologic elevations found within each location where the enzymes are found.
Phsyiologic and pathologic bone growth healing fracture, osteoblastic bone tumors, metastatic cancer to the bone, myeloma, osteomalacia. The enzymatic activity of alkaline phosphatase is stimulated in tissues during active metabolism, and as such there are both physiologic and pathologic causes of elevations in this enzyme. The first step in the diagnostic approach, therefore, should be to evaluate for physiologic causes of the elevation. Measure in a fasting state: The serum alkaline phosphatase level can increase up to two times the upper limit of normal after food ingestion, particularly those patients with blood type O or B, as a result of the intestinal isoenzyme.
Use age-appropriate reference populations for ranges: In children, serum alkaline phosphatase activity is considerably elevated and correlates well with the rate of bone growth. Additionally, patients over the age of 60 have somewhat higher values up to 1. At present, separate reference ranges are only required for children, based on age and gender; a single reference range is adequate for adults over the age of Use appropriate reference ranges for pregnant patients: Women in the third trimester of pregnancy have elevated alkaline phosphatase levels increases up to times normal because of an influx of placental alkaline phosphatase.
A separate reference range is required for pregnant patients. Ensure a non-genetic cause from family history: There are reports of a benign familial elevation in serum alkaline phosphatase levels because of increased levels of intestinal alkaline phosphatase.
Because of the diverse sources of the enzyme, the fist step in determining a non-physiologically elevated alkaline phosphatase level is to identify the source of the elevation. Electrophoretic separation into distinct isoenzymes on polyacrylamide gel or Sepharose is the most sensitive and specific way to do this; however, these tests are not widely available and not commonly used. Both levels of these enzymes are usually elevated in parallel with the elevation in alkaline phosphatase level in patients with hepatobiliary disorders.
Alternatively, the source can be identified using tests that involve heat denaturation of the enzyme. The finding of an elevated serum alkaline phosphatase level in a patient with a heat-stable fraction strongly suggests that the placenta or a tumor the Regan isoenzyme is the source. Susceptibility to inactivation by heat increases, respectively, for the intestinal, liver, and bone alkaline phosphatases, bone being by far the most sensitive. This test is unreliable and neither sensitive nor specific as the above testing.
If the excess alkaline phosphatase is determined to be of liver origin, the patient should be evaluated for cholestatic or infiltrative liver disease. Initial testing should include a right upper quadrant ultrasound, which can assess the bile ducts as well as the parenchyma of the liver, as well as an antimitochondrial antibody, which is highly suggestive of primary biliary cirrhosis.
A finding of biliary dilatation suggests the presence of biliary tree obstruction. In this setting, or in the presence of choledocholithiasis, endoscopic retrograde cholangiopancreatography should be the next test in order to identify the cause of obstruction and, if possible, to intervene.
Patients with serum antimitochondrial antibodies should undergo liver biopsy to confirm the diagnosis of primary biliary cirrhosis.
If both the serum antimitochondrial antibody is negative and the right upper quadrant ultrasound reveals no abnormality, assess the degree of elevation in the serum alkaline phosphatase level. If the alkaline phosphatase level is less than this, the results of all other liver-enzyme tests are normal, and the patient has no symptoms, observation alone can be pursued. Because elevations in serum alkaline phosphatase originate predominantly from the liver and the bone, focus on causes of high bone isoenzymes should be pursued if the elevation is determined to be non-hepatic in origin and no other clear source exists.
The bone isoenzyme is elevated as a result of increased osteoblastic activity. Beyond these disease processes, evaluation of skeletal health and specific bone disorders should be pursued within the clinical context of the patient.
Likewise, concerning the diagnosis of non-bone, non-liver causes of elevated alkaline phosphatase, the diagnostic work-up has the potential to be vast and should be guided by the clinical context of the patient. A complete medical history is perhaps the single most important part of the evaluation of the patient with elevated serum alkaline phosphatase levels, particularly focusing on the common causes as noted above. Concerning hepatic causes of elevated alkaline phosphatase, the clinical history should focus on the symptoms of liver disease — their nature, pattern of onset, and progression — and the associated risk factors.
The symptoms of liver disease include constitutional symptoms such as fatigue, weakness, nausea, poor appetite, malaise as well as the more liver-specific symptoms of jaundice, dark urine, light stools, itching, abdominal pain, and bloating.
Major risk factors that should be sought out in the history include details of alcohol use, medications including herbal compounds, prescribed medications, illicit medications and over-the-counter medications , personal habits, sexual activity, travel, parenteral exposure, recent surgery, recent travel history and family history of liver disease. However, many of these patients are asymptomatic. The physical examination usually complements rather than replaces the need for additional diagnostic approaches during the evaluation of an elevated serum alkaline phosphatase.
Typical findings in liver disease are icterus, hepatomegaly, hepatic tenderness, splenomegaly, spider angiomata, palmar erythema, excoriations, muscle-wasting, ascites, edema, dilated abdominal veins, asterixis, confusion, gynecomastia, testicular atrophy.
Skeletal examination may reveal bony tenderness or deformities. Having a high index of suspicion for particular diseases helps guide the diagnostic work-up.
Included are diagnostic methods related to common diseases presenting with elevated serum alkaline phosphatase:. Obstruction of the bile ducts:Dilatation may be initially visualized by ultrasound and confirmed by endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography, which may also be able to diagnose the etiology.
Primary biliary cirrhosis:The presence of anti-mitochondrial antibody in the context of elevated alkaline phosphatase with no overt abnormalities should prompt a liver biopsy demonstrating bile duct destruction and granulomatous cholangitis, which is diagnostic as well as important in staging the disease. Primary sclerosing cholangitis:p-ANCA is positive in most patients, though endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography demonstrating multifocal beaded bile duct strictures is diagnostic.
Medication induced: there are more than medications that have been reported to cause liver injury. Being aware of the side effects of medications both prescription and non-prescription is important. Diagnosis of drug-induced liver injury often requires the exclusion of viral, toxic, cardiovascular, inheritable, and malignant causes. Often in clinical practice, a trial without the suspected medication followed by rechecking the serum alkaline phosphatase is performed.
Primary malignancy and metastases to the liver:These lesions are usually demonstrated on ultrasound, occasionally they require biopsy for a tissue diagnosis. Sarcoidosis:Lesions may be seen on ultrasound, often necessitating a liver biopsy, which demonstrates the characteristic noncaseating granulomas, in order to distinguish from malignancy.
Exclusion of drugs and other causes of granulomatous disease should occur as well. Fatty liver:Various radiographic methods can detect the presence of fat within the liver, commonly seen on right upper quadrant ultrasound.
Fatty liver can be associated with obesity, diabetes, alcohol ingestion, chemotherapy. Amyloidosis:Hepatomegaly can be demonstrated on radiographic studies that may show inhomogeneous liver involvement. Liver biopsy demonstrating birefringence with Congo red stain establishes the diagnosis; however, it does not establish the type of amyloidosis. As such, fat, skin, or rectal biopsies are preferred if possible. Rarely will the physician encounter emergent conditions with an isolated elevated alkaline phosphatase that needs to be treated prior to the appropriate diagnostic work-up.
In emergent conditions associated with elevated alkaline phosphatase i. McGraw Hill. Kaplan, MM. The New England Journal of Medicine.. Sarac, F, Saygili, F. Biotechnology and Biotechnology Equipment. All rights reserved. No sponsor or advertiser has participated in, approved or paid for the content provided by Decision Support in Medicine LLC.
Login Register. Powered By Decision Support in Medicine. Jump to Section I. Diagnostic Approach. What is the differential diagnosis for this problem? Historical information important in the diagnosis of this problem. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.
Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem. Management while the Diagnostic Process is Proceeding. What's the evidence?
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Jump to Section I. Interesting Articles. Trending Recommended. This therapy can treat postmenopausal women with osteoporosis, although there are risks involved with prolonged use. PTH helps regulate the levels of calcium, vitamin D, and phosphorus in your bones and blood. Elevated alkaline phosphatase in patients with cancer normally spans throughout the bones or liver. Powered By Decision Support in Medicine.
Itching elevated alk. 5 causes for the increase of alkaline phosphatase
Bilirubin may rise above its normal level of 2. Any disorder that causes liver enzyme elevations and high bilirubin levels can cause itching. As many as 20 percent of people with hepatitis C experience pruritus, or intense itching, according to the HCV Advocate. Itching increases in people with more advanced disease. Diseases that block the bile ducts, such as primary sclerosing cholangitis, also often cause intense itching.
Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs.
Elevated serum alkaline phosphatase · generalized pruritus · Dx?
ICP is a diagnosis of exclusion, meaning that other causes of impaired liver function and cholestasis, such as viral hepatitis, biliary obstructions or strictures, or autoimmune hepatitis, among others, must be ruled out before the diagnosis can be made. Regardless of the reason for elevated bile acids, however, the treatment to reduce the risks to the pregnancy should be followed.
Currently the most sensitive test available to detect Intrahepatic Cholestasis of Pregnancy is the serum bile acid test, a blood test to measure the level of bile acids. It is often referred to as total bile acids, bile salts, or bile acid salts. Research suggests that elevated bile acids may be linked to risks to the unborn baby. Other studies in the same area have also found a correlation between higher bile acid levels and respiratory issues.
Many doctors will not diagnose without elevated bile acids, but some doctors and specialists may diagnose based upon symptoms consistent with the disorder or elevated liver functions alone.
Some doctors who are not specialists may not be familiar with the bile acid test, so it may be necessary to request it by name. In most cases it will take days to receive results of the bile acid test since it is processed in only a few specialty labs and must be sent out. This should be taken into consideration in cases where you have developed Intrahepatic Cholestasis of Pregnancy late in your pregnancy. Bile acids are not thought to be the cause of itching in Intrahepatic Cholestasis of Pregnancy.
It has been well-documented that bile acid levels do not correlate well with the intensity of itching a person experiences. Because of this, it is possible for bile acids to be normal for weeks or even months after itching begins. If your initial tests appear normal, but you continue to experience symptoms, you should be retested every week or two weeks as long as symptoms persist.
Quest Diagnostics and Lab Corp. A normal liver function panel does not rule out the disorder, however, the test results return within hours instead of days, which can provide your doctor with information more promptly. When liver functions are elevated they may be elevated prior to elevated bile acids, after elevated bile acids, or at the same time.
There are many items analyzed in this set of tests. The following are important to note regarding Intrahepatic Cholestasis of Pregnancy. View an example of results and reference ranges for a Liver Function blood test. Since Intrahepatic Cholestasis of Pregnancy is a rare disease in the United States a rare disease is one defined as affecting less than , Americans at any given time, whereas ICP is estimated to affect approximately 6, Americans per year , some doctors may not have a working knowledge of the disease.
Your doctor may not know of the disease, and if he or she does, may not know much about it or may even have misconceptions regarding the condition. At one time Intrahepatic Cholestasis of Pregnancy was considered a benign condition, meaning that it does not pose a risk to the baby, and some may still regard it as such.
You may need to take educational materials with you to your appointment to help your doctor learn more educational brochures and provider information. Print these materials and share them with your doctor rather than mentioning that you found the information on the internet. Given that it is so uncommon, your doctor may not be convinced at first that you may have the disorder. Be prepared for skepticism and understand that as long as your doctor is willing to run the proper tests it is not important.
If your doctor is resistant to learning more about the condition or if he or she is unwilling to run the test for bile acids then it may be time to seek a second opinion.
SMFM physician locator. Diagnosis Diagnosis. Serum bile acids Currently the most sensitive test available to detect Intrahepatic Cholestasis of Pregnancy is the serum bile acid test, a blood test to measure the level of bile acids. The two major USA labs blood test codes and links to their website below. Elevation of either or both of these may indicate that you have ICP. Some doctors will diagnose based solely upon elevation of these liver enzymes, both of which are produced when liver cells are damaged.
This liver enzyme is less specific to the liver, and is a by-product of bone formation as well as produced by the placenta. It is normal to have elevation of this enzyme during any pregnancy. Elevated bilirubin may also lead to jaundice. When bilirubin is elevated it is generally only mildly elevated. GGT is rarely elevated Other tests included in a liver function or complete metabolic panel are not specific to Intrahepatic Cholestasis of Pregnancy, but if they are abnormal discuss with your doctor what this may indicate.
Understand the uncommon nature of Intrahepatic Cholestasis of Pregnancy Since Intrahepatic Cholestasis of Pregnancy is a rare disease in the United States a rare disease is one defined as affecting less than , Americans at any given time, whereas ICP is estimated to affect approximately 6, Americans per year , some doctors may not have a working knowledge of the disease.