What is the meaning and management of elevated bilirubin levels?

Management of Elevated Bilirubin Levels

Elevated bilirubin requires prompt evaluation of the underlying cause with management tailored to the specific etiology, focusing on preventing complications like kernicterus in infants or addressing obstructive pathology in adults. 1

Diagnostic Approach

Initial Assessment

• Determine if hyperbilirubinemia is conjugated (direct) or unconjugated (indirect)
• Obtain fractionated bilirubin levels (total and direct)
• Complete laboratory evaluation:
  • Complete blood count
  • Liver function tests (AST, ALT, GGT, alkaline phosphatase)
  • Albumin and protein levels
  • Prothrombin time/INR 1, 2

Imaging

• Abdominal ultrasound is first-line imaging for suspected obstructive jaundice
• Consider MR Cholangiography (MRCP) for non-invasive visualization of biliary anatomy
• CT scan with contrast for suspected malignancy 1

Management Based on Patient Population

Neonatal Hyperbilirubinemia

1. Unconjugated Hyperbilirubinemia

   • Implement phototherapy when total serum bilirubin (TSB) reaches:

     • ≥15 mg/dL at 25-48 hours of age
     • ≥18 mg/dL at 49-72 hours of age
     • ≥20 mg/dL after 72 hours of age 1, 3

   • Use intensive phototherapy (blue-green spectrum, 430-490 nm) with irradiance of at least 30 mW/cm² per nm 4

   • Consider exchange transfusion when:

     • TSB approaches exchange transfusion threshold despite intensive phototherapy
     • TSB ≥25 mg/dL (medical emergency)
     • Signs of acute bilirubin encephalopathy 4, 1

2. Pathologic Jaundice (requires urgent evaluation)

   • Jaundice presenting within first 24 hours of life
   • TSB rising >5 mg/dL per day
   • TSB >17 mg/dL
   • Signs of serious illness 3

Adult Hyperbilirubinemia

1. Unconjugated Hyperbilirubinemia

   • Mild elevation with normal liver enzymes may indicate Gilbert's syndrome (benign condition in 5-10% of population) 5
   • Evaluate for hemolysis with hemoglobin, haptoglobin, reticulocyte count 2

2. Conjugated Hyperbilirubinemia (Obstructive Jaundice)

   • Therapeutic interventions:

     • ERCP is first-line for most obstructive cases (diagnostic and therapeutic)
     • Obtain brush cytology/biopsies during ERCP to rule out malignancy
     • Consider stent placement for symptomatic patients 1

   • For choledocholithiasis:

     • ERCP with sphincterotomy and stone extraction (success rate 80-95%)
     • Advanced endoscopic techniques for stones >15mm 1

   • For malignant obstruction:

     • Metal stents for patients expected to survive >3 months
     • Plastic stents for expected survival <3 months
     • Consider surgical bypass for good performance status patients with expected survival >6 months 1

Special Considerations

Monitoring

• Regular monitoring of bilirubin levels until resolution
• Monitor renal function in patients with hyperbilirubinemia
• For infants with prolonged jaundice, measure direct bilirubin to rule out pathologic causes 1

Common Pitfalls

1. Failure to recognize urgent situations:

   • Cholangitis (Charcot's triad: fever, RUQ pain, jaundice) requires urgent biliary decompression
   • Rapidly rising bilirubin in neonates can lead to kernicterus and permanent neurological damage 1

2. Inadequate phototherapy in neonates:

   • Ensure proper irradiance and surface area coverage
   • Line bassinet/incubator with aluminum foil or white material when TSB approaches exchange levels
   • Persistent or rising TSB despite intensive phototherapy suggests hemolysis 4

3. Missing underlying pathology:

   • Always obtain tissue samples during ERCP for suspicious strictures
   • Consider less common causes like drug-induced liver injury 1, 2

Nutritional Support

• Address malnutrition in patients with prolonged jaundice
• For breastfed infants, maintain breastfeeding while determining cause of jaundice
• Ensure 8-12 feedings per day for infants 1

By systematically evaluating the cause of elevated bilirubin and implementing appropriate management strategies, complications can be minimized and outcomes improved.