Management of Elevated Liver Enzymes in a Breastfeeding Woman

Diagnostic Approach

The American College of Gastroenterology recommends repeating liver function tests, including ALT, AST, alkaline phosphatase, and total bilirubin, within 2-5 days to determine if values are stable, improving, or worsening in a breastfeeding woman with mild elevations (<2× ULN) 1
A complete liver panel, including total and direct bilirubin, alkaline phosphatase, gamma-glutamyl transferase (GGT), international normalized ratio (INR), and complete blood count with platelets, should be ordered to identify the underlying cause of elevated liver enzymes 1
Viral hepatitis serologies, including hepatitis B surface antigen (HBsAg), anti-HBc, hepatitis C antibody with reflex to HCV RNA, and hepatitis A IgM if clinically indicated, should be obtained 1
Metabolic and autoimmune screening, such as fasting glucose, lipid panel, hemoglobin A1c, iron studies, antinuclear antibody (ANA), anti-smooth muscle antibody (SMA), and anti-mitochondrial antibody (AMA), should be performed 1
Hepatic ultrasound to assess for steatosis, masses, or biliary obstruction is recommended 1

The FIB-4 score, calculated as age × AST / (platelet count × √ALT), can be used to stratify the risk of fibrosis in patients with non-alcoholic fatty liver disease (NAFLD) 1 2
A FIB-4 score of <1.3 indicates low risk, 1.3-2.67 indicates intermediate risk, and >2.67 indicates high risk 1 2
Patients with intermediate or high risk should undergo transient elastography (FibroScan) or serum enhanced liver fibrosis (ELF) testing 1
The American Association for the Study of Liver Diseases recommends monitoring liver enzymes every 2-4 weeks until normalized in patients with mild elevations 1

Referral to gastroenterology/hepatology is recommended if there is evidence of advanced liver disease or cirrhosis on imaging or non-invasive testing, suspicion of autoimmune hepatitis, or ALT remains >3× ULN after 4-6 weeks 1
The European Association for the Study of the Liver recommends referral to a specialist if there is progressive elevation of liver enzymes despite removal of potential offending agents or if the FIB-4 score suggests intermediate or high risk for fibrosis 1