Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access
Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc
Journal website http://www.gastrores.org

Case Report

Volume 7, Number 2, April 2014, pages 64-68


Significantly Elevated Liver Alkaline Phosphatase in Congestive Heart Failure

Figures

Figure 1.
Figure 1. Transthoracic echocardiography (in end-systolic phase) shows an evidence of severe cardiomyopathy with ejection fraction < 20%.
Figure 2.
Figure 2. This graph illustrates how ALP levels responded to various types of diuretic therapies along with the other liver enzymes progressions; total bilirubin, AST and ALT levels.
Figure 3.
Figure 3. Three consecutive axial MR images, images A-C, of the abdomen demonstrating a normal appearing liver with moderate perihepatic ascites along with gallbladder wall thickening. Biliary dilatation is not demonstrated, with a normal pancreatic duct and a common bile duct measuring 3 mm.
Figure 4.
Figure 4. Liver Biopsy Pathology Slides. (A) The hematoxylin and eosin (H&E) stain at 100× depicting dilated sinusoids of the liver suggestive of right-sided heart failure. (B) The H&E stain at 400× depicting erythrocytes in hepatic plates suggestive of left-sided heart failure. (C) The H&E stain at 400× demonstrating biliary infarction consistent with mild biliary obstruction.

Tables

Table 1. Initial Laboratory Studies the Patient Presented With on Admission
 
Labs on admissionPatient’s valueNormal value
Prothromin time (PT)14.210.0 - 13.5 s
INR1.2< 1.5
Activated partial thromboplastin time (aPTT)31.625.0 - 36.0 s
Aspartate aminotransferase (AST)2810 - 35 units/L
Alanine aminotransferase (ALT)2110 - 35 units/L
Albumin2.23.5 - 5.2 g/dL
Alkaline phosphatase65835 - 129 units/L
Liver alkaline phosphatase9544-84%
Bilirubin total (Bili T)10.1 - 1.0 mg/dL
Erythrocyte sedimentation rate (ESR)90 - 20 mm/h
pro-BNP11,18450 - 192 pg/mL
Hemoglobin A1C> 17.44.8-5.9%

 

Table 2. Serological Studies That Were Checked to Evaluate the Elevated ALP
 
Serological evaluation of ALPPatient’s valueNormal value
Thyroid stimulating hormone (TSH)2.420.27 - 4.20 mcIU/mL
Iron level5237 - 145 mcg/dL
Total iron binding capacity (TIBC)281228 - 428 mcg/dL
Iron saturation1920-55%
Ferritin4713 - 150 ng/mL
Ceruloplasmin4316 - 45 mg/dL
Anti-nuclear antibodyNegativeNegative
Mitochondrial antibodyNondetectedNondetected
Smooth muscle antibodyNondetectedNondetected
Hepatitis A IgMNondetectedNondetected
Hepatitis B core antibody IgMNondetectedNondetected
Hepatitis B surface antigenNondetectedNondetected
Hepatitis C antibodyNondetectedNondetected
Angiotensin converting enzyme858 - 52 units/L
Alfa fetoprotein1.10 - 13.0 ng/mL
Carcinoembryonic antigen (CEA)4.7< 5.0 ng/mL
Cancer antigen 19-9 (CA 19-9)20.0 - 35.0 units/mL
Cytomegalovirus (CMV) antibody IgM0.030 - 0.69 index
Cytomegalovirus (CMV) antibody IgG0.20.0 - 0.8 AI
Herpes simplex virus (HSV) 1 antibody IgM0.780.00 - 0.90 index
Herpes simplex virus (HSV) 1 antibody IgG4.40.0 - 0.8 AI
Quantiferon TB-goldNegativeNegative