Gastroenterol Res

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

Figure 1. Transthoracic echocardiography (in end-systolic phase) shows an evidence of severe cardiomyopathy with ejection fraction < 20%.

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. 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. 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.

**Table 1.** Initial Laboratory Studies the Patient Presented With on Admission
Labs on admission	Patient’s value	Normal value
Prothromin time (PT)	14.2	10.0 - 13.5 s
INR	1.2	< 1.5
Activated partial thromboplastin time (aPTT)	31.6	25.0 - 36.0 s
Aspartate aminotransferase (AST)	28	10 - 35 units/L
Alanine aminotransferase (ALT)	21	10 - 35 units/L
Albumin	2.2	3.5 - 5.2 g/dL
Alkaline phosphatase	658	35 - 129 units/L
Liver alkaline phosphatase	95	44-84%
Bilirubin total (Bili T)	1	0.1 - 1.0 mg/dL
Erythrocyte sedimentation rate (ESR)	9	0 - 20 mm/h
pro-BNP	11,184	50 - 192 pg/mL
Hemoglobin A1C	> 17.4	4.8-5.9%

Table 1. Initial Laboratory Studies the Patient Presented With on Admission

Labs on admission

Patient’s value

Normal value

Prothromin time (PT)

14.2

10.0 - 13.5 s

INR

1.2

< 1.5

Activated partial thromboplastin time (aPTT)

31.6

25.0 - 36.0 s

Aspartate aminotransferase (AST)

10 - 35 units/L

Alanine aminotransferase (ALT)

10 - 35 units/L

Albumin

2.2

3.5 - 5.2 g/dL

Alkaline phosphatase

658

35 - 129 units/L

Liver alkaline phosphatase

44-84%

Bilirubin total (Bili T)

0.1 - 1.0 mg/dL

Erythrocyte sedimentation rate (ESR)

0 - 20 mm/h

pro-BNP

11,184

50 - 192 pg/mL

Hemoglobin A1C

> 17.4

4.8-5.9%

**Table 2.** Serological Studies That Were Checked to Evaluate the Elevated ALP
Serological evaluation of ALP	Patient’s value	Normal value
Thyroid stimulating hormone (TSH)	2.42	0.27 - 4.20 mcIU/mL
Iron level	52	37 - 145 mcg/dL
Total iron binding capacity (TIBC)	281	228 - 428 mcg/dL
Iron saturation	19	20-55%
Ferritin	47	13 - 150 ng/mL
Ceruloplasmin	43	16 - 45 mg/dL
Anti-nuclear antibody	Negative	Negative
Mitochondrial antibody	Nondetected	Nondetected
Smooth muscle antibody	Nondetected	Nondetected
Hepatitis A IgM	Nondetected	Nondetected
Hepatitis B core antibody IgM	Nondetected	Nondetected
Hepatitis B surface antigen	Nondetected	Nondetected
Hepatitis C antibody	Nondetected	Nondetected
Angiotensin converting enzyme	85	8 - 52 units/L
Alfa fetoprotein	1.1	0 - 13.0 ng/mL
Carcinoembryonic antigen (CEA)	4.7	< 5.0 ng/mL
Cancer antigen 19-9 (CA 19-9)	2	0.0 - 35.0 units/mL
Cytomegalovirus (CMV) antibody IgM	0.03	0 - 0.69 index
Cytomegalovirus (CMV) antibody IgG	0.2	0.0 - 0.8 AI
Herpes simplex virus (HSV) 1 antibody IgM	0.78	0.00 - 0.90 index
Herpes simplex virus (HSV) 1 antibody IgG	4.4	0.0 - 0.8 AI
Quantiferon TB-gold	Negative	Negative

Table 2. Serological Studies That Were Checked to Evaluate the Elevated ALP

Serological evaluation of ALP

Patient’s value

Normal value

Thyroid stimulating hormone (TSH)

2.42

0.27 - 4.20 mcIU/mL

Iron level

37 - 145 mcg/dL

Total iron binding capacity (TIBC)

281

228 - 428 mcg/dL

Iron saturation

20-55%

Ferritin

13 - 150 ng/mL

Ceruloplasmin

16 - 45 mg/dL

Anti-nuclear antibody

Negative

Mitochondrial antibody

Nondetected

Smooth muscle antibody

Nondetected

Hepatitis A IgM

Nondetected

Hepatitis B core antibody IgM

Nondetected

Hepatitis B surface antigen

Nondetected

Hepatitis C antibody

Nondetected

Angiotensin converting enzyme

8 - 52 units/L

Alfa fetoprotein

1.1

0 - 13.0 ng/mL

Carcinoembryonic antigen (CEA)

4.7

< 5.0 ng/mL

Cancer antigen 19-9 (CA 19-9)

0.0 - 35.0 units/mL

Cytomegalovirus (CMV) antibody IgM

0.03

0 - 0.69 index

Cytomegalovirus (CMV) antibody IgG

0.2

0.0 - 0.8 AI

Herpes simplex virus (HSV) 1 antibody IgM

0.78

0.00 - 0.90 index

Herpes simplex virus (HSV) 1 antibody IgG

4.4

0.0 - 0.8 AI

Quantiferon TB-gold

Negative