•Temperature 36.8°C, pulse 72 bpm, BP 110/72mmHg, SaO₂ 98-100% on RA.

•Alert, no jaundice with no stigmata of chronic liver disease.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable, with no lymph nodes palpable.

•Cardiovascular: HS dual. No murmur.

•His chest is clear on auscultation.

•Abdominal examination reveals a soft, non-tender abdomen, with no organomegaly.

•No signs of oedema.

Investigations

•CBC:

–WBC 9.7 x 10⁹/L;

–haemoglobin 10g/dL;

–platelets 265 x 10⁹/L.

•Bilirubin 15μmol/L.

•ALP 350 IU/L.

•ALT 50 IU/L (baseline normal).

•Renal function is normal.

What are the common causes of increased ALP?

•Physiological.

•Adolescence.

•Pregnancy.

•Pathological.

•Bile obstruction.

•Hepatocellular disease, e.g. cirrhosis, hepatitis, alcoholic liver disease.

•Hepatocellular carcinoma.

•Infiltrative disease, e.g. TB, sarcoidosis.

•Primary biliary cirrhosis.

•Primary sclerosing cholangitis (PSC).

•Bone disease.

How would you evaluate the origin of ALP?

•ALP isoenzyme.

•Gamma-glutamyltransferase (GGT).