Wallach's Interpretation of Diagnostic Tests: Pathways to Arriving at a Clinical Diagnosis (677 page)

   Adverse reaction to therapeutic drug (e.g., chlorpropamide) (progressive elevation of serum ALP may be first indication that drug therapy should be halted); may be 2–20 times normal

   Increased synthesis of ALP in the liver

   Diabetes mellitus—44% of diabetic patients have 40% increase of ALP.

   Parenteral hyperalimentation of glucose.

   Liver diseases with increased ALP

   Less than three to four times increase lacks specificity and may be present in all forms of liver disease.

   Two times increase: acute hepatitis (viral, toxic, alcoholic), acute fatty liver, cirrhosis.

   Two to ten times increase: nodules in the liver (metastatic or primary tumor, abscess, cyst, parasite, TB, sarcoid); is a sensitive indicator of a hepatic infiltrate.

   Increase more than two times the upper limit of normal in patients with primary breast or lung tumor with osteolytic metastases is more likely caused by liver than by bone metastases.

   Five times increase: infectious mononucleosis, postnecrotic cirrhosis.

   Ten times increase: carcinoma of the head of the pancreas, choledocholithiasis, and drug cholestatic hepatitis.

   Fifteen to twenty times increase: primary biliary cirrhosis, primary or metastatic carcinoma. The GGT-to-ALP ratio >2.5 is highly suggestive of alcohol abuse.

   Chronic therapeutic use of anticonvulsant drugs (e.g., phenobarbital, phenytoin).