From the Guidelines
Elevated bilirubin with normal liver enzymes and lipase is most likely due to a benign condition such as Gilbert's syndrome, and no specific treatment is needed, with reassurance and periodic monitoring of bilirubin levels being appropriate for asymptomatic patients. This condition is characterized by unconjugated hyperbilirubinemia, which is a common finding in patients with diffuse hepatocellular disease, inability of the liver to handle a bilirubin load, or a bilirubin metabolism deficiency 1. The role of imaging in unconjugated hyperbilirubinemia is primarily to exclude other potential diagnoses, such as mechanical obstruction, and to confirm the absence of a mechanical obstruction 1.
Some key points to consider in the diagnosis and management of elevated bilirubin with normal liver enzymes and lipase include:
- The patient's symptoms, such as fatigue, abdominal pain, or darkening jaundice, which may warrant further investigation
- The patient's medical history, including any previous episodes of jaundice or liver disease
- The results of additional blood tests, such as complete blood count, reticulocyte count, and haptoglobin, which may help to identify underlying causes of hemolysis or liver disease
- The results of imaging studies, such as ultrasound of the liver and biliary system, which may help to exclude mechanical obstruction or other causes of jaundice
In general, patients with elevated bilirubin and normal liver enzymes and lipase can be managed conservatively, with reassurance and periodic monitoring of bilirubin levels, as long as they remain asymptomatic 1. However, if symptoms develop or if the patient's condition changes, further investigation and management may be necessary to rule out other underlying causes of jaundice.
From the Research
Elevated Bilirubin with Normal Liver Enzymes and Lipase
- Elevated bilirubin levels can indicate an underlying disease state, and the evaluation of jaundice should start with a careful history and physical examination, followed by directed imaging of the biliary tree and liver 2.
- The initial laboratory evaluation should include assays for bilirubin (total and fractionated), a complete blood cell count, aspartate transaminase, alanine transaminase, gamma-glutamyltransferase, alkaline phosphatase, albumin, prothrombin time, and international normalized ratio 3.
- Measuring fractionated bilirubin allows for determination of whether the hyperbilirubinemia is conjugated or unconjugated, which can help differentiate between potential causes such as hemolysis, hepatitis, or biliary obstruction 4, 5.
- Unconjugated hyperbilirubinemia can occur with increased bilirubin production caused by red blood cell destruction, such as hemolytic disorders, and disorders of impaired bilirubin conjugation, such as Gilbert syndrome 5.
- Conjugated hyperbilirubinemia can occur in disorders of hepatocellular damage, such as viral and alcoholic hepatitis, and cholestatic disorders, such as choledocholithiasis and neoplastic obstruction of the biliary tree 5, 6.
- A liver biopsy may be considered when serologic testing and imaging fail to elucidate a diagnosis, to stage a condition, or when multiple diagnoses are possible 6.