Predominantly Raised ALP

This guideline applies to adults over 18 years.




  • Abnormal LFTs have often not been investigated adequately- Many patients present with end stage liver disease without a previous diagnosis of liver disease were noted to have previous abnormal liver tests.
  • Mild rises should not be overlooked– the extent of liver blood test abnormality is not a guide to clinical significance (e.g. chronic Hep C with a lower ALT may be worse than acute Hep A with an ALT>1000).
  • Patients should be considered for investigation irrespective on the abnormality- Do not overlook mild rises and consider patients for investigation if no obvious cause regardless of the duration or level of the abnormality.
  • However, the majority of adults with abnormal LFTs will be identified to have metabolic associated steatotic liver disease (MASLD, previously known as non-alcoholic fatty liver disease or NAFLD) or alcohol-related liver disease (ARLD). Most simply require reinforcement of lifestyle advice and ongoing assessment in primary care.



Red flags

  • Synthetic failure – jaundice, low albumin, ascites, prolonged INR, encephalopathy
  • Features of malignancy –
    • weight loss and marked cholestasis
    • weight loss >60yrs with any of:diarrhoea, back pain, abdominal pain, nausea or vomiting, constipation, new onset diabetes
    • Jaundice in patient >40years
  • ALT >300 iu/l
  • Dilatation of common bile duct on ultrasound or liver/gallbladder/pancreatic mass lesions



Key Features of Assessment

(In patients > 80 years old or with significant frailty use clinical to avoid unnecessary investigation)


In addition to usual assessment check for:

  • Contributing conditions – diabetes, viral hepatitis, autoimmune disease, cancer, coeliac, haemochromatosis, IBD (risk of primary sclerosing cholangitis or autoimmune hepatitis)
  • Excessive alcohol or recreational drug use
  • Pregnancy
  • Medications– esp. statins, anticonvulsants, antibiotics (particularly flucloxacillin, erythromycin, doxycycline or co-amoxiclav), paracetamol.
  • Herbal treatments – black cohosh, weight loss/bodybuilding supplements, Chinese herbal medicines, green tea extract, turmeric.





If GGT raised – liver origin. If ALP raised in isolation, consider bone origin.




Follow flow chart as above plus in addition to usual management particularly review medications:

  • Recent statins, antibiotics, NSAIDs; STOP any drugs known to be associated with drug-induced liver injury.
  • If there is a temporal relationship between a new medication and LFT changes, consider drug-induced liver injury and discontinuation medication. Repeat LFTs in 1-3 months depending on clinical judgement.



Advice and Guidance

Please send advice and guidance requests via e-RS to: http://rms.cornwall.nhs.uk/primary_care_clinical_referral_criteria/rms/primary_care_clinical_referral_criteria/gastro/rcht_hepatology_advice_and_guidance




Acutely Unwell  (e.g. sepsis, severe encephalopathy, severe ascites restricting movement and breathing, GI bleeding.) - Admit via Acute GP (Mon-Fri 8am-6pm, Sat-Sun 9am-6pm) or via the on-call Medical SpR outside of these hours.


Painful cholestasis or painful jaundice&sepsis– admit general surgery


Pregnant with abnormal LFTs: refer to Maternity Day Assessment unit via on-call O&G SpR


Suspected cancer – Fast trackUSC Upper GI Cancer

  • >40 years old with jaundice
  • Abnormal CT or ultrasound scan consistent with pancreatic, liver, or gallbladder cancer
  • Patient older than 60 years with weight loss and any of: diarrhoea, back pain, abdominal pain, nausea or vomiting, constipation, new onset diabetes


Weight loss and Cholestasis– Urgent referral (hepatology will triage and see ASAP due to risk of malignancy)


Jaundiced patients:

  • Painless jaundice - Arrange FBC, LFTs, INR and USS and refer urgently to the Rapid Access Jaundice clinic.


Symptomatic liver disease (ascites/encephalopathy):

Urgent Hepatology referral or urgent admission (particularly if unwell or gastrointestinal bleeding)


Primary biliary cholangitis (PBC)

  • ↑ALP + positive antimitochondrial antibody (AMA) - refer urgent hepatology 


Primary sclerosing cholangitis (PSC)

  • IBD + abnormal LFTS  - refer to hepatology

ALT>300 and asymptomatic:(if symptomatic refer depending on symptoms)

  • Refer hepatology A&G


For East-facing Cornwall practices. Please see South & West Devon DRSS Referral Guidelines



Supporting Information


For professionals:


For patients:




Page Review Information


Review date

April 2024

Next review date

April 2026


Speciality Lead GP


Dr Madeleine Attridge (Hepatology lead GP)







Dr Hyder Hussaini (Consultant Hepatologist RCHT)

Anna Barton (Principal Clinical Biochemist)