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Quick Reference
  • Total Bilirubin (Normal): 0.2-1.2 mg/dL
  • Direct Bilirubin (Conjugated): <0.3 mg/dL
  • Indirect Bilirubin (Unconjugated): <1.0 mg/dL
  • Clinical Jaundice Threshold: >2-3 mg/dL
  • Sample Type: Serum (protect from light)
  • Key Point: Direct vs indirect ratio helps identify pre-hepatic, hepatic, or post-hepatic causes

Test Description

What is Bilirubin?

Bilirubin is a yellow pigment produced from the breakdown of hemoglobin during the normal destruction of aged red blood cells.

Where Does Bilirubin Come From?

  • 80-85%: Senescent (aged) red blood cells
  • 15-20%: Ineffective erythropoiesis and breakdown of other heme-containing proteins (myoglobin, cytochromes)

The Liver's Role

The liver plays a central role in bilirubin metabolism:

  • Conjugation: Converts unconjugated bilirubin to conjugated (water-soluble) form
  • Excretion: Allows bilirubin to be excreted in bile
  • Diagnostic value: Measuring total and direct (conjugated) bilirubin helps differentiate between:
    • Hepatic disease
    • Biliary obstruction
    • Hemolytic disorders

Bilirubin Metabolism Pathway

Understanding bilirubin metabolism is essential for interpreting abnormal results:

  • Step 1 - Red Blood Cell Breakdown: Senescent RBCs are destroyed in the reticuloendothelial system (spleen, liver, bone marrow), releasing hemoglobin.
  • Step 2 - Heme Conversion: Hemoglobin is broken down into heme and globin. Heme is converted to biliverdin by heme oxygenase, then to unconjugated bilirubin by biliverdin reductase.
  • Step 3 - Transport to Liver: Unconjugated bilirubin (water-insoluble) binds to albumin in the bloodstream and is transported to the liver.
  • Step 4 - Hepatic Uptake: Hepatocytes take up unconjugated bilirubin from the blood.
  • Step 5 - Conjugation: Inside hepatocytes, the enzyme UDP-glucuronosyltransferase (UGT1A1) conjugates bilirubin with glucuronic acid, forming water-soluble conjugated bilirubin (direct bilirubin).
  • Step 6 - Biliary Excretion: Conjugated bilirubin is excreted into bile and flows through bile ducts to the intestine.
  • Step 7 - Intestinal Processing: In the intestine, bacteria convert conjugated bilirubin to urobilinogen. Most urobilinogen is excreted in feces (as stercobilin, giving stool its brown color); a small amount is reabsorbed and excreted in urine.

Direct vs. Indirect Bilirubin

  • Direct (Conjugated) Bilirubin: Water-soluble form that has been processed by the liver. Measured directly in lab assays. Elevated in hepatic disease and biliary obstruction.
  • Indirect (Unconjugated) Bilirubin: Water-insoluble form bound to albumin. Calculated as (Total Bilirubin - Direct Bilirubin). Elevated in hemolysis and genetic conjugation defects.
  • Total Bilirubin: Sum of direct and indirect bilirubin. Gives overall assessment but doesn't differentiate etiology.
Normal Ranges

Bilirubin levels are generally consistent across adult populations, though neonatal values differ significantly. Reference ranges may vary slightly between laboratories depending on the assay method used.

Swipe to see more
Population Total Bilirubin Direct Bilirubin Indirect Bilirubin
Adults (all genders) 0.2-1.2 mg/dL <0.3 mg/dL <1.0 mg/dL
Adults (SI Units) 3-21 µmol/L <5 µmol/L <17 µmol/L
Neonates (term, day 1) <6 mg/dL — —
Neonates (term, day 3-5) <12 mg/dL — —

Important Considerations

  • Clinical Jaundice: Visible yellowing of skin and sclera typically occurs when total bilirubin exceeds 2-3 mg/dL.
  • Gilbert Syndrome: Approximately 5-10% of the population has Gilbert syndrome, a benign genetic condition causing mild chronic elevation (usually 1-3 mg/dL) of unconjugated bilirubin, particularly during fasting or illness.
  • Neonatal Hyperbilirubinemia: Newborns have physiologically higher bilirubin levels due to increased RBC turnover, immature liver conjugation, and lack of intestinal bacteria. Phototherapy thresholds vary by age and risk factors.
  • Laboratory Method: Modern labs use diazo method or direct spectrophotometry. Results may not be directly comparable between different assay methods.
Clinical Significance

Elevated Total Bilirubin - Pattern Recognition

The pattern of bilirubin elevation (predominantly conjugated vs. unconjugated) is critical for differential diagnosis. A useful rule: if direct bilirubin is >50% of total bilirubin, consider the hyperbilirubinemia to be predominantly conjugated (direct).

Predominantly Unconjugated (Indirect) Hyperbilirubinemia

When indirect bilirubin is disproportionately elevated, consider pre-hepatic causes (increased production) or hepatic uptake/conjugation defects.

Increased Bilirubin Production (Hemolysis)

  • Hemolytic Anemias: Hereditary spherocytosis, G6PD deficiency, sickle cell disease, autoimmune hemolytic anemia. RBC destruction exceeds liver's conjugation capacity.
  • Ineffective Erythropoiesis: Thalassemia, megaloblastic anemia. Premature destruction of RBC precursors in bone marrow.
  • Hematoma Resorption: Large hematomas or internal bleeding can release significant hemoglobin, leading to mild hyperbilirubinemia.
  • Blood Transfusion Reactions: Hemolytic transfusion reactions cause acute RBC destruction.

Impaired Hepatic Uptake or Conjugation

  • Gilbert Syndrome: Benign genetic deficiency of UGT1A1 enzyme (reduced to ~30% of normal). Causes mild unconjugated hyperbilirubinemia (1-3 mg/dL), often exacerbated by fasting, illness, or stress. Affects 5-10% of population. No treatment needed.
  • Crigler-Najjar Syndrome Type I: Severe deficiency or absence of UGT1A1. Total bilirubin >20 mg/dL. Requires phototherapy and often liver transplantation.
  • Crigler-Najjar Syndrome Type II: Partial UGT1A1 deficiency (~10% activity). Total bilirubin 6-20 mg/dL. Responds to phenobarbital.
  • Neonatal Jaundice (Physiologic): Immature UGT1A1 enzyme in first week of life. Usually benign but requires monitoring to prevent kernicterus.
  • Drug-Induced: Rifampin, probenecid, and some antiretrovirals can impair hepatic uptake of bilirubin.

Predominantly Conjugated (Direct) Hyperbilirubinemia

When direct bilirubin is disproportionately elevated (>50% of total), consider hepatocellular injury or biliary obstruction (cholestasis).

Hepatocellular Disease (Impaired Excretion)

  • Viral Hepatitis: Hepatitis A, B, C, D, E. Inflammation impairs bilirubin excretion and causes conjugated hyperbilirubinemia. AST and ALT are markedly elevated.
  • Alcoholic Hepatitis: Acute alcohol-induced liver inflammation. Often presents with AST:ALT ratio >2:1 and elevated direct bilirubin.
  • Drug-Induced Liver Injury (DILI): Acetaminophen overdose, antibiotics (amoxicillin-clavulanate), anticonvulsants (phenytoin), statins, herbal supplements. Can cause hepatocellular or cholestatic patterns.
  • Cirrhosis: Advanced chronic liver disease with impaired synthetic and excretory function. Elevated bilirubin indicates poor prognosis (Child-Pugh class B or C).
  • Ischemic Hepatitis: "Shock liver" from profound hypotension. Causes massive transaminase elevation with bilirubin rising later.
  • Autoimmune Hepatitis: Immune-mediated destruction of hepatocytes. Check ANA, anti-smooth muscle antibodies.
  • Dubin-Johnson Syndrome: Rare genetic defect in MRP2 transporter causing impaired canalicular excretion of conjugated bilirubin. Black liver on imaging. Benign prognosis.
  • Rotor Syndrome: Rare genetic defect in hepatic uptake and storage. Conjugated hyperbilirubinemia without liver pigmentation. Benign prognosis.

Biliary Obstruction (Cholestasis)

  • Extrahepatic Obstruction: Choledocholithiasis (common bile duct stones), pancreatic cancer, cholangiocarcinoma, pancreatitis. Often presents with painless jaundice, pale stools, dark urine. ALP and GGT markedly elevated.
  • Intrahepatic Cholestasis: Primary biliary cholangitis (PBC), primary sclerosing cholangitis (PSC), drug-induced cholestasis (anabolic steroids, estrogens, chlorpromazine). Itch is a prominent symptom.
  • Sepsis/Infection: Severe infections can cause cholestasis through inflammatory cytokine effects on bile transporters.
  • Total Parenteral Nutrition (TPN): Prolonged TPN can cause cholestatic liver injury.

Mixed Hyperbilirubinemia (Both Direct and Indirect Elevated)

Many chronic liver diseases cause mixed patterns as liver function deteriorates.

Mixed Pattern Causes

  • Chronic Hepatitis: Hepatitis B or C with ongoing inflammation.
  • Cirrhosis (Decompensated): End-stage liver disease with multifactorial bilirubin elevation.
  • Hepatic Congestion: Right heart failure, Budd-Chiari syndrome (hepatic vein thrombosis).
  • Acute-on-Chronic Liver Failure: Acute decompensation in patients with underlying chronic liver disease.
Interpretation Guidelines

Classification of Hyperbilirubinemia

A systematic approach to elevated bilirubin based on the direct bilirubin fraction:

Swipe to see more
Classification Direct Bilirubin Primary Mechanism Key Differentials
Predominantly Unconjugated <20% of total Increased production or impaired conjugation Hemolysis, Gilbert syndrome, Crigler-Najjar
Predominantly Conjugated >50% of total Hepatocellular disease or cholestasis Hepatitis, cirrhosis, biliary obstruction
Mixed Pattern 20-50% of total Combined mechanisms Chronic liver disease, sepsis, heart failure

Clinical Decision-Making Algorithm

Diagnostic Approach to Jaundice

Step 1: Measure Total and Direct Bilirubin

Step 2: Calculate Indirect Bilirubin = Total - Direct

Step 3: Determine predominant pattern:

  • If Indirect >> Direct → Check CBC (hemolysis), reticulocyte count, haptoglobin, LDH
  • If Direct >> Indirect → Check AST, ALT, ALP, GGT to differentiate hepatocellular vs. cholestatic
  • If AST/ALT >> ALP → Hepatocellular injury (viral serologies, toxin screen)
  • If ALP/GGT >> AST/ALT → Cholestasis (abdominal ultrasound or CT, consider MRCP/ERCP)

Step 4: Imaging (ultrasound first-line for biliary obstruction)

Step 5: Consider liver biopsy if diagnosis unclear after initial workup

Interfering Factors

Factors That Falsely Increase Bilirubin

  • Hemolysis: In vitro hemolysis of blood sample releases hemoglobin, which can interfere with diazo assay and falsely elevate bilirubin measurements.
  • Lipemia: Severe hypertriglyceridemia or lipemic samples can cause spectrophotometric interference, falsely elevating results.
  • Medications: Rifampin, atazanavir, and indinavir can cause unconjugated hyperbilirubinemia by competing for hepatic uptake or inhibiting UGT1A1.
  • High-Dose Vitamin C (Ascorbic Acid): Can interfere with diazo method in some assays.

Factors That Falsely Decrease Bilirubin

  • Light Exposure: Bilirubin is photosensitive and degrades with prolonged light exposure. Blood tubes should be protected from light, especially for neonatal samples. Prolonged exposure can decrease measured bilirubin by 30-50%.
  • Delayed Processing: Bilirubin is unstable at room temperature. Samples should be processed within 4 hours or stored in the dark at 4°C.
  • Caffeine: May slightly decrease bilirubin levels, though clinical significance is minimal.

Physiologic Factors Affecting Bilirubin

  • Fasting: Prolonged fasting (12-24 hours) can increase unconjugated bilirubin by 25-50%, particularly in Gilbert syndrome patients. This is due to decreased hepatic uptake and conjugation.
  • Caloric Restriction: Low-calorie diets may transiently increase bilirubin, especially in individuals with Gilbert syndrome.
  • Physical Exertion: Strenuous exercise may cause mild transient elevations due to subclinical hemolysis.
  • Menstrual Cycle: Some women experience slight increases in bilirubin during menstruation.
  • Illness/Stress: Acute illness, infection, or surgery can unmask Gilbert syndrome, causing temporary elevation in unconjugated bilirubin.

Medications That Affect Bilirubin Metabolism

Increase Bilirubin:

  • Protease Inhibitors: Atazanavir, indinavir (inhibit UGT1A1)
  • Rifampin: Competes for hepatic uptake
  • Probenecid: Inhibits biliary excretion
  • Estrogens/Oral Contraceptives: Can cause cholestasis
  • Anabolic Steroids: Cholestatic effect

Decrease Bilirubin:

  • Phenobarbital: Induces UGT1A1, used therapeutically in Crigler-Najjar Type II
  • Anticonvulsants: Some (e.g., phenytoin) induce hepatic enzymes, potentially lowering bilirubin
Clinical Pearls
  • "Jaundice is scleral icterus plus skin": The sclera (whites of eyes) show yellowing first because of high elastin content with affinity for bilirubin. Check sclera in natural light for subtle hyperbilirubinemia.
  • The "50% Rule" for conjugated hyperbilirubinemia: If direct bilirubin is >50% of total bilirubin, classify as conjugated hyperbilirubinemia and think hepatocellular or cholestatic disease.
  • "Direct is a lie": The name "direct bilirubin" comes from the lab assay (directly reacts with diazo reagent), not the metabolic pathway. It's actually the conjugated form. Similarly, "indirect" is unconjugated.
  • Gilbert syndrome is common and benign: Affects 5-10% of people, especially males. Causes mild jaundice during fasting or illness. No treatment needed. Reassure patients it's not liver disease.
  • Pale stools + dark urine = obstruction: This combination strongly suggests biliary obstruction. Conjugated bilirubin is water-soluble and spills into urine (dark urine), while lack of bilirubin in intestine causes pale/clay-colored stools.
  • Hemolysis triad: Elevated indirect bilirubin + elevated LDH + decreased haptoglobin = hemolysis. Check reticulocyte count and peripheral smear.
  • AST:ALT ratio guides etiology: AST:ALT >2:1 suggests alcoholic liver disease. AST:ALT <1 suggests viral hepatitis or NASH. Combine with bilirubin pattern for diagnosis.
  • "Kernicterus is preventable": In neonates, unconjugated bilirubin can cross the blood-brain barrier causing irreversible brain damage. Closely monitor and treat neonatal jaundice with phototherapy before levels reach >20-25 mg/dL (risk factors: prematurity, hemolysis, sepsis).
  • Check for occult hemolysis: In patients with unexplained indirect hyperbilirubinemia, always consider chronic low-grade hemolysis from prosthetic heart valves, mechanical trauma, or paroxysmal nocturnal hemoglobinuria (PNH).
  • Don't forget drug-induced causes: Many medications cause hepatotoxicity or cholestasis. Always review medication list, including over-the-counter drugs and herbal supplements (e.g., green tea extract, kava).
  • Timing matters in hepatic obstruction: In acute biliary obstruction (e.g., choledocholithiasis), bilirubin rises over days. But AST/ALT may spike first (from back-pressure injury), then normalize even if obstruction persists, while bilirubin and ALP remain elevated.
  • "Murphy's sign + elevated bilirubin": Suggests cholecystitis with possible choledocholithiasis or Mirizzi syndrome (gallstone impacted in cystic duct compressing common hepatic duct). Order imaging urgently.
  • Bilirubin as prognostic marker: In cirrhosis, elevated bilirubin is a component of Child-Pugh score and MELD score. Bilirubin >3 mg/dL indicates advanced disease and poor prognosis without transplant.
  • TPN-associated cholestasis: Long-term total parenteral nutrition can cause cholestatic liver injury, especially in infants and children. Monitor LFTs regularly in TPN patients.
  • Think sepsis: Sepsis and systemic infection can cause cholestatic hyperbilirubinemia even without primary liver disease. Cytokines impair bile transporters.
  • Serial measurements in acute hepatitis: In viral or drug-induced hepatitis, bilirubin may continue to rise even after transaminases peak and start to fall. This lag is normal and doesn't indicate worsening.
References
  1. Kratz, A., Ferraro, M., Sluss, P. M., & Lewandrowski, K. B. (2004). Laboratory reference values. New England Journal of Medicine, 351, 1548-1564.
  2. Lee, M. (Ed.). (2009). Basic skills in interpreting laboratory data. Ashp.
  3. Farinde, A. (2021). Lab values, normal adult: Laboratory reference ranges in healthy adults. Medscape. https://emedicine.medscape.com/article/2172316-overview?form=fpf
  4. Nickson, C. (n.d.). Critical Care Compendium. Life in the Fast Lane • LITFL. https://litfl.com/ccc-critical-care-compendium/
  5. Farkas, Josh MD. (2015). Table of Contents - EMCrit Project. EMCrit Project. https://emcrit.org/ibcc/toc/
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