1. Differential Diagnosis of Alkaline Phosphatase B9402030 陳建佑

2. Physiology Alkaline phosphatase(ALP) is present in all tissues throughout the entire body, but is particularly concentrated in 1. Liver & Bile duct 2. Bone 3. Parathyroid gland ALP elevations >4 times normal occur primarily in patients with cholestatic liver disorders, infiltrative liver diseases such as cancer, and bone conditions characterized by rapid bone turnover (e.g., Paget's disease).

3. Liver Disease Cholestasis  normal serum & urinary bilirubin Cholecystitis & Cholangitis  no abdomen pain (Murphy’s sign), WBC normal & no fever (acute), no jaundice, normal serum bilirubin Cirrhosis  no ascites, normal ALT & serum albumin, <3 times normal elevation of ALP Hepatitis  normal ALT & serum & urinary albumin, no tenderness Drugs toxictosis  no drug using history liver tumor (?) liver metastases (?)

4. Bone Disease Paget's disease  abnormal serum Ca & P (normal serum Ca & P, very high ALP) Fractured bone  no trauma Multiple myeloma  no other hematology problems (e.g. prolong PT, anemia,) Osteomalacia / Rickets  hypercalcemia (hypocalcemia, hypophosphatemia,VitD deficiency) Osteosarcoma (?) Bone metastases (?)

5. Parathyroid Gland Hyperparathyroidism  Serum PTH level should be tested PTH Serum Calcium Likely Type high primary hyperparathyroidism highlow or normal secondary hyperparathyroidism

6. Others Myelofibrosis  No splenomegaly, no coagulating problem Polycythemia vera  normal CBC (RBC count 8~11 x10 12 cell/L) Leukemoid reaction  no infection, normal WBC count