Nonalcoholic fatty liver disease presenting with an isolated elevated alkaline phosphatase

To define a subset of patients with nonalcoholic fatty liver disease (NAFLD) with isolated elevations in alkaline phophatase.

NAFLD is a common referral to Gastroenterologists and Hepatologists. We have noted a subset of patients with biopsy proven NAFLD who present with an isolated elevation in alkaline phosphatase instead of the more typical aminotransferase elevations.

A review of the liver biopsy database at Brooke Army Medical Center was performed with the key identifiers of "steatosis" and "steatohepatitis." Patients were separated into 2 groups depending on whether they presented with isolated elevated alkaline phosphatase (group 1), or more typical aminotransferase elevations (group 2). Multiple variables were analyzed to determine any significant differences between these groups.

A total of 297 liver biopsies were evaluated. Of these, 135 biopsies were included in the study. Group 1 consisted of 14 patients and group 2 had 121 patients. Patients in group 1 were more likely to be older females (P<0.05). Within group 1, those with steatohepatitis were older than those with steatosis (P<0.05). When analyzed with regard to histopathology, patients with steatosis in group 1 were more likely female than group 2 patients (P=0.03). Those with steatohepatitis in group 1 were older than group 2 patients (P=0.001). Five of the 7 patients with steatohepatitis in group 1 had advanced liver disease at the time of biopsy.

Older female patients with isolated elevated alkaline phosphatase and risk factors for NAFLD should be evaluated for evidence of significant steatohepatitis.