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Gastroenterology
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Elevated Alkaline Phosphatase
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GGT distinguishes hepatobiliary from bone origin.
Decision
Outcome
Decision
Elevated serum alk phos. First test?
✓
Check GGT
✗
Liver biopsy
Decision
GGT?
✓
Elevated → likely biliary origin
✓
Normal → likely bone origin
Decision
RUQ ultrasound + AMA?
✓
AMA positive or abnormal parenchyma → liver biopsy
✓
Dilated bile ducts → ERCP/MRCP
✓
Both normal → reassess; consider MRCP for PSC
Outcome
Liver biopsy — likely PBC (AMA-positive)
Outcome
ERCP for choledocholithiasis, stricture, malignancy
Outcome
MRCP for primary sclerosing cholangitis
Outcome
Bone source: Paget, bone metastases, fracture, osteomalacia, hyperparathyroidism, growth (children)
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