What to ask in history when bilirubin (bili) is elevated?

Key History Elements for Elevated Bilirubin Evaluation

When evaluating a patient with elevated bilirubin, a thorough history should focus on identifying the underlying cause by specifically asking about alcohol use, medications, symptoms of biliary obstruction, and risk factors for viral hepatitis. 1, 2

Initial History Assessment

• Timing and onset of symptoms:

  • Duration of jaundice (acute vs chronic)
  • Jaundice in first 24 hours of life (in neonates) is always pathological 2
  • Jaundice persisting beyond 2 weeks requires evaluation 2

• Medication and substance history:

  • Complete drug history (prescribed medications, over-the-counter drugs, herbal supplements) 1
  • Alcohol consumption (current and past intake in average units per week, consider AUDIT C) 1
  • Illicit drug use, especially injecting drug use 1

• Risk factors for viral hepatitis:

  • Travel history to endemic areas
  • Ethnicity/country of birth (to explore possible risk of hepatitis B or C) 1
  • Sexual history
  • Blood transfusion history
  • Occupational exposures 1

Specific Symptoms to Inquire About

• Abdominal symptoms:

  • Right upper quadrant pain (suggests biliary colic, cholecystitis, or cholangitis) 1
  • Fever and chills (suggests cholangitis) 1
  • Abdominal pain pattern (colicky vs constant)
  • Change in stool color (pale stools suggest biliary obstruction)
  • Change in urine color (dark urine suggests conjugated hyperbilirubinemia)

• Constitutional symptoms:

  • Weight loss (concerning for malignancy) 1
  • Pruritus (suggests cholestasis) 1
  • Fatigue 1
  • Nausea 1

Medical History

• Pre-existing conditions:

  • History of liver disease
  • Inflammatory bowel disease (associated with PSC) 1
  • Autoimmune conditions (personal or family history) 1
  • Metabolic syndrome features (central obesity, hypertension, diabetes/insulin resistance, dyslipidemia) 1
  • Recent muscle injury (can cause elevated transaminases) 1
  • History of tick bites (possible cause of certain infections) 1

• Family history:

  • Family history of liver disease or jaundice 1, 2
  • Family history of blood disorders 2
  • Family history of Gilbert syndrome or other hereditary hyperbilirubinemias

Distinguishing Between Types of Hyperbilirubinemia

For direct (conjugated) hyperbilirubinemia, focus on:

• History of biliary disease (gallstones, prior biliary surgery)
• Symptoms of biliary obstruction (RUQ pain, fever)
• Risk factors for viral hepatitis
• Alcohol consumption
• Medication use that could cause drug-induced liver injury 1

For indirect (unconjugated) hyperbilirubinemia, focus on:

• Family history of jaundice
• History of hemolytic disorders
• Recent hematoma or blood transfusion 3

Special Considerations

• In patients with known PSC, inquire about symptoms of cholangitis which may mimic drug-induced liver injury biochemically 1
• For patients with marked elevations in ALT (>1000 U/L), focus on risk factors for acute viral hepatitis (A, E, cytomegalovirus) 1
• In children, obtain maternal, neonatal, nutritional, and developmental history 1, 2

Common Pitfalls to Avoid

• Failing to obtain a complete medication history, including herbal supplements
• Overlooking alcohol as a common cause of liver disease
• Not asking about risk factors for viral hepatitis
• Assuming mildly abnormal liver tests will normalize without investigation 1
• Relying solely on the extent of liver blood test abnormality as a guide to clinical significance 1

Remember that the clinical assessment is critical in determining which tests should be ordered and how they should be interpreted, as many patients with significant liver fibrosis may have liver enzymes in the normal reference range 1.