Bilirubin is an orange-yellow pigment, a waste product primarily produced by the normal breakdown of heme. Heme is a component of hemoglobin, which is found in red blood cells (RBCs). Bilirubin is ultimately processed by the liver so that it can be removed from the body. This test measures the amount of bilirubin in the blood to evaluate a person's liver function or to help diagnose anemias caused by RBC destruction (hemolytic anemia).
RBCs normally degrade after about 120 days in circulation. Bilirubin is formed as the liver breaks down and recycles aged red blood cells.
Two forms of bilirubin can be measured or estimated by laboratory tests:
Unconjugated bilirubin is formed when heme is released from hemoglobin. It is carried by proteins to the liver. In the liver, sugars are attached (conjugated) to bilirubin to form conjugated bilirubin.
Conjugated bilirubin enters the bile and passes from the liver to the small intestines, where it is further broken down by bacteria and eventually eliminated in the stool. Thus, the breakdown products of bilirubin give stool its characteristic brown color. Normally, the level of conjugated bilirubin in the blood is very low.
The bilirubin test is included in the comprehensive metabolic panel (CMP) and the liver panel, which are often used as general health screenings.
Usually, an initial test measures the total bilirubin level (unconjugated plus conjugated bilirubin).
If the total bilirubin level is increased, the laboratory can use a second test to detect water-soluble forms of bilirubin, called "direct" bilirubin. The direct bilirubin test provides an estimate of the amount of conjugated bilirubin present.
Subtracting the direct bilirubin level from the total bilirubin level helps estimate the "indirect" level of unconjugated bilirubin.
A small amount (approximately 250 to 350 milligrams, or about 4 milligrams per kilogram of body weight) of bilirubin is produced daily in a normal, healthy adult. Most bilirubin (70%-90%) comes from damaged or degraded RBCs, with the remaining amount coming from the bone marrow or liver. Normally, small amounts of unconjugated bilirubin are released into the blood, but almost no conjugated bilirubin is present.
If the bilirubin level increases in the blood, a person may appear jaundiced, with a yellowing of the skin and/or whites of the eyes. The pattern of bilirubin test results can give the healthcare practitioner information regarding the condition that may be present.
Some tests are used to detect liver damage and evaluate liver function and may include:
Liver panel, often comprised of:
ALT (Alanine aminotransferase)
ALP (Alkaline phosphatase)
AST (Aspartate aminotransferase)
Bilirubin, Total (conjugated and unconjugated), Direct (conjugated) and Indirect (unconjugated)
GGT (Gamma-glutamyl transferase)
Prothrombin time (PT): the liver produces proteins involved in the clotting (coagulation) of blood; the PT measures clotting function and, if abnormal, may indicate liver damage.
Urine bilirubin (often as part of a urinalysis)
Some tests may be used to detect infections that affect the liver, such as:
Epstein-Barr virus (EBV)
Tests used to detect decreased red blood cell survival may include:
Complete blood count (CBC)
Reticulocyte count (if CBC is abnormal)
Blood smear: to visualize RBCs under a microscope
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