Bilirubin:- Part 2 – Conjugated, Direct Bilirubin (Conjugated hyperbilirubinemia)

Sample

1. This test is done in the serum of the patient.
2. A random sample can be taken.
   1. This is ideal if the patient has nothing except water 4 to 8 hours before the sample.
3. The sample is stable at 4 °C for 3 days.
4. Protect the sample from the light because bilirubin is photo-oxidized (photosensitive).

Precautions

1. Avoid hemolysis and lipemic serum, which will give a false result.
2. Avoid drugs that will increase the total bilirubin level like:
   1. Anabolic steroids.
   2. Antibiotics.
   3. Antimalarial drugs.
   4. Chlorpropamide.
   5. Methotrexate.
   6. Antihypertensive drug-like methyldopa.
   7. Oral contraceptives.
   8. Antituberculous drugs like rifampin.
3. Medications that will decrease the bilirubin level are:
   1. Penicillin.
   2. Caffein.
   3. Barbiturates.
4. Exposure of the sample to sunlight or ultraviolet light may decrease the level.

Pathophysiology

1. Bilirubin is yellow to the green pigment of bile derived from the porphyrin structure of hemoglobin.
   1. Excessive bilirubin within cells and the tissue causes jaundice (Icterus) or yellowness of the skin.
   2. Hyperbilirubinemia is caused by:
      1. Destruction of the RBCs like hemolytic jaundice.
      2. Diseases affecting the metabolism and excretion of bilirubin in the liver.
      3. Obstruction like gall stones or pancreatic tumors and certain drugs like:
         1. Chlorpromazine and phenothiazine derivatives.
         2. Estrogen hormones.
         3. Halothane anesthetic drugs.
2. Bilirubin estimation is one of the liver function tests.
3. It is raised in the hepatic and post-hepatic types of jaundice.
4. Clinically jaundice appears when the level of bilirubin is more than 2 mg/dl.
5. Direct (or conjugated) bilirubin. Direct bilirubin dissolves in water (water-soluble) and is synthesized in the liver from indirect bilirubin.
   

   Bilirubin metabolism summary

Normal Values

1. Total bilirubin  = 0.3 to1.0 mg/dL or 5.1 to 17.0 mmol/L
2. Direct bilirubin   =  0.1 to 0.3 mg/dL or 1.0 to 5.1 mmol/L
3. Indirect bilirubin (total bilirubin minus direct bilirubin level) = 0.2–0.7 mg/dL

Another source Total bilirubin level

Age	Premature  mg/dL	Full-term   mg/dL	Adult   mg/dL
Cord blood	<2 mg	<2.0
0 to 1 day	<8.0	1.4 to 8.7
1 to 2 days	<12.0	3.4 to 11.5
3 to 5 days	<16.0	1.5 to 12.0
5 days to 60 years			0.3 to 1.2
60 to 90 year			0.2 to 1.1
>90 year			0.2 to 0.9

Raised level of direct bilirubin is seen in:

1. Gallstones.
2. Gallbladder tumors.
3. Inflammatory scarring or obstruction of extrahepatic ducts.
4. Extensive liver metastasis.
5. Dubin-Johnson syndrome.
6. Rotor syndrome.
7. Drugs may cause cholestasis.

Raised direct and indirect bilirubin is seen in:

1. Hepatocellular disease.
2. Hepatitis (viral disease).
3. Cirrhosis.
4. Dubon-Johnson syndrome.

Panic value needs action are:

• Total bilirubin infants >15 mg/dL will require phototherapy.
• Total bilirubin in infants >20 mg/dL require blood transfusion.
• Untreated infants will get kernicterus and may lead to permanent brain damage.

Please see more details on bilirubin Total part 1.

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