From the Guidelines
Management of hyperbilirubinemia in adults requires a comprehensive approach that includes identifying and treating the underlying cause, as well as providing supportive care to minimize morbidity, mortality, and improve quality of life. The first step is determining whether the hyperbilirubinemia is predominantly conjugated (direct) or unconjugated (indirect) through laboratory testing 1. For unconjugated hyperbilirubinemia caused by hemolysis, treatment focuses on addressing the hemolytic process with corticosteroids, immunosuppressants, or splenectomy depending on the etiology. Gilbert syndrome, a common benign cause, requires no specific treatment. For drug-induced hyperbilirubinemia, discontinuation of the offending agent is essential.
In cases of conjugated hyperbilirubinemia due to biliary obstruction, endoscopic retrograde cholangiopancreatography (ERCP) with stent placement or surgical intervention may be necessary 1. For hepatocellular causes like viral hepatitis, specific antivirals such as entecavir or tenofovir for hepatitis B, or direct-acting antivirals for hepatitis C are indicated. Ursodeoxycholic acid (10-15 mg/kg/day) is beneficial for cholestatic conditions like primary biliary cholangitis. Severe cases with acute liver failure may require N-acetylcysteine (loading dose 150 mg/kg IV over 1 hour, followed by 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours) and consideration for liver transplantation.
Supportive measures include:
- Maintaining hydration
- Providing nutritional support
- Monitoring for complications like hepatic encephalopathy Pruritus, a common symptom, can be managed with:
- Cholestyramine (4 g before and after breakfast)
- Antihistamines
- Rifampicin (150-300 mg twice daily) in refractory cases. The initial imaging evaluation of a patient presenting with conjugated hyperbilirubinemia will include a right upper quadrant US, as recommended by multiple society guidelines 1.
From the Research
Management of Hyperbilirubinemia in Adults
The management of hyperbilirubinemia in adults involves a series of steps to diagnose and treat the underlying cause of elevated bilirubin levels.
- The initial evaluation should include fractionated bilirubin, a complete blood count, alanine transaminase, aspartate transaminase, alkaline phosphatase, γ-glutamyltransferase, prothrombin time and/or international normalized ratio, albumin, and protein 2.
- Imaging with ultrasonography or computed tomography can differentiate between extrahepatic obstructive and intrahepatic parenchymal disorders 2.
- A more extensive evaluation may include additional cancer screening, biliary imaging, autoimmune antibody assays, and liver biopsy 2.
Diagnostic Approach
The diagnostic approach to hyperbilirubinemia in adults starts with a careful history and physical examination, followed by directed imaging of the biliary tree and liver 3.
- The best approach to evaluating a patient with jaundice is to start with a careful history and physical examination, followed by imaging assessment of the biliary tree and liver 3.
- Algorithm models that incorporate bilirubin levels in their predictor models for outcomes in patients with chronic liver disease can be useful in evaluating patients with jaundice 3.
Treatment of Hyperbilirubinemia
The treatment of hyperbilirubinemia in adults depends on the underlying cause of the elevated bilirubin levels.
- In cases of isolated hyperbilirubinemia following cytarabine-based chemotherapy, a lower dose of cytarabine for future treatment should be considered 4.
- In general, the treatment of hyperbilirubinemia involves addressing the underlying cause, such as treating hemolytic disorders or hepatocellular damage 5, 2.