Liver and pancreas
Bilirubine totaal
The yellow breakdown product of red blood cells; raised with a liver condition, a blocked bile duct or increased breakdown of blood cells.
Everything about this testWhat it measures
Bilirubin is formed during the breakdown of old red blood cells. The liver takes it up, makes it water-soluble (conjugated or direct bilirubin) and excretes it with the bile into the intestine. Total bilirubin is the sum of the not yet processed (unconjugated or indirect) part and the processed part. If the value rises considerably, the skin and the whites of the eyes turn yellow (jaundice). Which part is raised says something about the cause: before the liver (too much breakdown), in the liver (uptake or processing) or after the liver (drainage through the bile ducts).
- Blocked bile drainage (cholestasis) due to gallstones or a narrowing of the bile ducts
- Liver damage due to hepatitis, alcohol, medicines or liver cirrhosis
- Increased breakdown of red blood cells (hemolysis)
- Gilbert's syndrome: a harmless inherited variant in which the liver processes bilirubin somewhat more slowly
High
A slightly raised total bilirubin in someone without symptoms and with normal other liver values is very often due to Gilbert's syndrome (Gilbert's disease). This is a harmless inherited trait in which the liver processes bilirubin more slowly; the value rises with fasting, illness, lack of sleep or heavy exercise, and no treatment is needed. After a large bruise or with increased breakdown of red blood cells, it is also mainly the unconjugated part that rises. If the conjugated part is raised, together with alkaline phosphatase and gamma-GT, the bile drainage is blocked, for example by gallstones; symptoms are then pain in the upper right abdomen, itching, dark urine and pale stool. With liver inflammation or advanced liver disease, both parts are raised, usually together with ALAT. Rarely: a tumor that blocks the bile ducts.
Low
A low bilirubin has no significance. Some medicines, a lot of coffee and smoking can lower the value slightly; the test is not used for that.
If your result is abnormal
With a slightly raised bilirubin and otherwise normal liver values, the GP usually has the conjugated part measured and repeats the measurement after a few weeks; if only the unconjugated part is raised and the blood count is normal, this fits Gilbert's syndrome and further testing is not needed. With a raised conjugated bilirubin or jaundice, an ultrasound of the liver and bile ducts follows and, if needed, referral to a gastroenterologist.
Reliability
Total bilirubin is a good measure of jaundice and of the severity of a liver condition, but a single value says little about the cause. That requires the split into conjugated and unconjugated bilirubin, together with ALAT, alkaline phosphatase, gamma-GT and the blood count. According to the Dutch GP guideline (NHG), an isolated slightly raised bilirubin with otherwise normal liver values usually needs no further testing, because Gilbert's syndrome is then by far the most likely explanation.
Limitations
- Fasting, a strict diet, lack of sleep, fever and heavy exercise raise bilirubin temporarily, especially in people with Gilbert's syndrome.
- Hemolysis in the tube (red blood cells broken down by a difficult blood draw or finger prick) and prolonged exposure of the sample to light disturb the measurement.
- Some medicines (including rifampicin, some HIV inhibitors and anabolic steroids) raise the value without liver damage.
- Measurement methods and reference values differ between laboratories; men have slightly higher values than women on average.
How common is this
According to Erfelijkheid.nl, about 1 in 20 people have Gilbert's syndrome; this makes it by far the most common cause of a slightly raised bilirubin in healthy adults, more often in men. Gallstones occur in about 1 in 10 adults, usually without symptoms. Chronic viral hepatitis and liver cirrhosis are much rarer.
Who is this useful for
Useful with yellow skin or yellow whites of the eyes, dark urine or pale stool, with pain in the upper right abdomen, with a known liver condition to monitor its course, and when increased breakdown of blood cells is suspected (then together with the blood count). Also as part of a liver panel. In healthy adults without symptoms, the test mainly leads to finding the harmless Gilbert's syndrome.
Downsides and risks
- A slightly raised bilirubin due to Gilbert's syndrome is often wrongly taken for liver disease and then leads to unnecessary worry.
Sources
Always discuss an abnormal result with your GP. If a result is strongly abnormal, we try to reach you as soon as possible. Read your result yourself as well and contact your GP if in doubt. A test does not make a diagnosis. Read more about risks and results