Case 2

So some considerations when deciding how to work up an asymptomatic patient with only an elevated ALP are

1. The magnitude of the ALP elevation. Mild elevations (two to three times normal) in otherwise healthy dogs may just warrant a wait-and-see approach, while further diagnostics are warranted in dogs with marked elevations or with an upward trend.

2. The patient's age. Don't forget that young dogs can have a normal ALP elevation due to bone remodeling and growth. Conversely, an older patient may be more likely to have hepatic neoplasia or benign nodular regeneration, so an ultrasonographic examination would be worth considering in these cases.

3. Any salient physical examination findings. Any swellings or masses should be investigated in case of an occult neoplasia or infection.

4. Breed. Is it a breed prone to hepatopathies (i.e. West Highland white terriers, Doberman pinschers)? Also remember that, for reasons that are not entirely clear, Scottish terriers can have an elevated ALP (whether or not they have liver disease).2

In Spot's case, given his mobility issues and the possible need for anti-inflammatory drugs, you talk to the owner about pelvic radiographs and fasting and postprandial bile acid testing, and she agrees. The radiographs confirm the presence of moderate degenerative joint disease in the hips.

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