liver function tests

jaundice bilirubin look in urine and eyes

Bilirubin Levels Chart (Normal, Low, High Bilirubin Levels Explained)

Bilirubin Levels Chart is a table of common bilirubin levels that cause jaundice yellowish color of the skin and eyes sclera, including normal bilirubin levels, high bilirubin levels, and low bilirubin levels in the same place.

Where bilirubin comes from and where does bilirubin go to?

Bilirubin comes from the degradation of hemoglobin and cells breakdown by spleen or other organs, bilirubin enters bloodstream as large insoluble molecule which has the term (unconjugated), when reaches the liver, hepatic cells perform chemical reaction to make bilirubin soluble in the blood by bound it to the glucuronic acid by the enzyme glucuronyltransferase which then called (conjugated), conjugated bilirubin go from the liver to the intestine and undergoes reduction to the form called stercobilirubin which give the stool its yellowish color, another part of direct bilirubin go to urine through the kidney after being transformed to a compound called urobilinogen (urine dye) which gives the urine the yellowish color.

Measuring Bilirubin at the lab: scientists measure conjugated bilirubin and report it as (direct bilirubin), and measures total bilirubin values, then calculated the unconjugated bilirubin by subtracting direct from the total, the result is the estimated indirect bilirubin (unconjugated)

When your doctor requests a bilirubin test, this means direct bilirubin (DBil), indirect bilirubin, and total-value bilirubin (TBil), the bilirubin test for the newborns is “total bilirubin and/or indirect bilirubin”

Hyperbilirubinemia, Jaundice, icterus are medical terms for high bilirubin levels in the blood and urine, clearly, jaundice means a yellow discoloration of the skin and icterus means discoloration of the eyes, while kernicterus is a medical condition that means brain cells damage due to high bilirubin levels in the blood, usually at levels such as 30 mg/dl, Bilirubin is a highly neurotoxic substance.
Medical shortcodes for TSB, DSB, ISB are total, direct, indirect serum bilirubin respectively.
Total bilirubin is the sum of all bilirubin forms in the blood and does not represent a different type of bilirubin in the body.

The bilirubin showed in urine and skin at serum bilirubin levels between 3.0 to 5.0 mg/dl, skin jaundice and eyes yellowish discoloration appear, urine color become dark yellow or as light tea when direct bilirubin is high in the blood when indirect bilirubin is higher than 25mg/dl in the blood, it may show greenish plasma color as a result of the severe elevation of indirect bilirubin (due to increased activity of biliverdin reductase enzyme which reduces biliverdin to bilirubin).

what does dark yellow jaundice urine look like?

Comprehended bilirubin levels chart for all ages (adults and newborns)

Low bilirubin levels explained

Low levels of bilirubin are generally not concerning and are not monitored as there are no studies confirming the risk for a low level of bilirubin.

Bilirubin results like:

  • Total bilirubin less than 0.4 is not a concern of abnormalities.
  • Indirect less than 0.3 is another insignificant bilirubin level.

Normal bilirubin levels

Normal bilirubin level is a bilirubin value that means there are no diseases that could be found in the sources of synthesis, processing, and removing of bilirubin.

  • normal bilirubin values lie between reference ranges, the lower limit, and the upper limit.
  • Direct bilirubin 0, 0.1, 0.2, and 0.3 is normal results and cannot be a cause of jaundice unless indirect bilirubin continue to be high.
  • Indirect bilirubin 0.8, 0.7, 0.6, 0.5,0.4, and 0.3 are all normal levels of blood bilirubin.
  • Total bilirubin level 0.9,0.8,0.7,0.6,0.5,0, and 4.0 are normal and not jaundice whatever is the result of direct and indirect bilirubin.

Recommendation: if it’s the first time you take a bilirubin test, there is no further investigation when results is normal, if you’re on medication, then you’re just fine and continue to keep it normal.

Borderline Bilirubin results:
Are the bilirubin levels that reach the normal upper limits or slightly above, can’t be taken seriously as jaundice, and need for new test after a few days, sometimes borderline bilirubin levels show up when the person is on medications.

  • Bilirubin direct 0.4 with normal indirect and total bilirubin results.
  • Bilirubin indirect level is 0.9 and total is 1.0 mg/dl.
  • Bilirubin total is 1.1 and normal direct and indirect bilirubin.

False bilirubin results:
Lab errors must be confirmed by retesting bilirubin after a few days, physiological causes as dehydration show pale yellow skin and deep yellow eye’s white area which may be confused with jaundice, results may be as:

  • Bilirubin direct level is higher than the total bilirubin level, for instance; direct 1.0 and total 0.8 mg/dl.
  • Bilirubin levels show slight increase above the upper normal limit; for ex. Total 1.1 and 1.2 mg/dl.
  • Total bilirubin results are very low: 0, 0.1, 0.2, 0.3 mg/dl which could be false low results or wrong test.

High bilirubin levels (hyperbilirubinemia)

Causes of hyperbilirubinemia:

  • High Direct bilirubin helps in diagnosis the liver function and post hepatic jaundice caused by obstruction of bilirubin in common bile ducts (obstructive jaundice) by gallstones, tumors, or scarring of bile ducts, also some diseases cause liver function failure such as viral hepatitis, alcoholic liver disease, and drug reactions.
  • High Indirect bilirubin helps in diagnosis of pre-hepatic jaundice caused by rapid hemolysis of red blood cells of infants or adults such as hemolytic anemia, pernicious anemia, also blood  transfusion reaction, and Cirrhosis cause high indirect jaundice, inability to produce the enzyme which converting indirect to direct is a common cause of jaundice without a disease, this case known as inherited Gilbert syndrome and cause relative elevation in indirect bilirubin.

High bilirubin (total) is either due to:

  1. High indirect bilirubin level with normal or slightly elevated direct bilirubin, commonly seen by those with excessive hemolytic anemia for any cause and newborn jaundice due to new birth immaturity or RH incompatibility between mother and baby, may be called hemolytic jaundice, for example:
  • Indirect bili. 3.0 high, direct bili. 0.3 normal.
  • Indirect bilirubin 10.0 very high, slightly elevated direct bilirubin 0.5 mg/dl.

2. High direct Bilirubin level with normal or slightly elevated indirect bilirubin, commonly seen in results of obstructive jaundice due to hepatitis A for children or stones, for example:

  • Direct bilirubin 7.5 mg/dl high, indirect bilirubin normal 0.6 mg/dl.
  • Direct bilirubin 11.0 mg/dl high, indirect bilirubin slightly elevated 0.9 mg/dl.

3. Both conjugated and unconjugated bilirubin is elevated, values are almost the same, commonly results from hepatic diseases, for instance:

  • Direct bilirubin 9.0 mg/dl, indirect bilirubin 8.0 mg/dl.
  • Indirect bilirubin 12.0 mg/dl, direct bilirubin 11.5 mg/dl.

Common bilirubin levels in infant newborns:

newborn jundice
Newborns high bilirubin on skin
  • 1 day after birth: direct 0.2, indirect 3.5 mg/dl, total is 3.7
  • 2 days: direct 0.3, indirect 5.0, and total is 5.3
  • 1 week to 10 days after birth: indirect 13.0, direct 1.0, and total bilirubin 14.0 mg/dl.
  • 2 weeks: should be reduced towards the normal limits, if increased; may show total bilirubin over 20 mg/dl, which is very high and incubation is required, extremely elevated total bilirubin higher than 30 mg/dl is a serious condition and may lead to Kernicterus which is deadly brain damage.

For treatment and follow up tests of newborn jaundice, please visit this topic; jaundice in newborns, and bilirubin blood test results.

High bilirubin with no visible disease
Gilbert, Crigler-Najjar syndrome, and alcohols are common reasons for high bilirubin levels without an obvious disease.

  • In Crigler-Najjar syndrome, at birth or in infancy the child show jaundice with Severe unconjugated hyperbilirubinemia, if bilirubin is extremely elevated can cause condition called kernicterus, the accumulation of unconjugated bilirubin in the brain and nerve tissues and lead to brain damage and death.
  • In Gilbert’s syndrome: also has the medical terms constitutional hepatic dysfunction and familial non-hemolytic jaundice, seen by accident during checkup testing, the one still be confused where and when he acquired this bilirubin, all hemolytic tests and hepatic causes are absent, the bilirubin still constantly at near high levels for all the life as the original reason is “born with gene mutation caused abnormal bilirubin metabolism”

Remarks: Hereditary jaundice show steady bilirubin levels and continuous follow up.

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Updated: Jaundice Levels Chart in Newborns (Jaundice Levels 5,12,15,18,20,30 explained)

Jaundice levels chart is to know the normal Jaundice Levels in newborn infants, the risk jaundice levels that need treatment for the newborn baby, and the new guidelines for effective treatment and fasts getting rid of jaundice.
Jaundice has another medical term “icterus” and means a yellowish tinge to the skin and the white part of the eye (sclera) that is caused by an excess of bilirubin in the blood, which is called in medicine hyperbilirubinemia.

Serum indirect bilirubin level is the most common elevated bilirubin in newborns, high direct bilirubin in newborn infants seen in rare conditions of biliary atresia which requires surgical intervention to prevent any liver damage to the child, and in neonatal hepatitis.

Risky Jaundice levels:

The normal total bilirubin level is any value from 0.3 to 1.0 mg/dL. In a newborn, due to less mature liver function and absence of microorganisms (both are processing bilirubin), normal bilirubin level in a newborn under 5 mg/dL, then go higher in many newborns, the infant bilirubin levels usually fall substantially by day 7, the bilirubin risk level in newborns are more than 15 mg/dL before 48 hours old, more than 18 mg/dL before 72 hours old, more than 20 mg/dL anytime for both healthy born or preterm delivery).


Why do Newborns children have jaundice and high bilirubin?

High indirect bilirubin in newborns is a result of accelerated RBCs breakdown due to:

  • Blood type incompatibility between the mother and her newborn, recommended for Blood film examination to observe hemoglobin level, NRBCs and reticulocyte count.
  • Lack of oxygen (hypoxia), Arterial blood gases test is recommended.
  • Diseases that can affect the liver, liver function tests are recommended.
  • Certain congenital infections.

Hyperbilirubinemia risk levels in infants:

  1. Lower Risk: More than or equal to 38 weeks and well, recommended to evaluate for phototherapy and check TSB in 4-24 hours.
  2. Medium Risk: More than or equal to 38 weeks and hyperbili risk factors OR 35 to 37 6/7 weeks and well, recommended to evaluate for phototherapy and check TSB in 4-24 hours.
  3. Higher Risk: 35 to 37 6/7 weeks and hyperbili risk factors, recommended to evaluate for phototherapy and check TSB in 4-24 hours.

Who is at risk of high bilirubin levels?

Hyperbilirubinemia Risk Factors are:

  • TSB/TcB in high-risk zone
  • Jaundice in the first 24 hours
  • ABO incompatibility with positive direct Coomb’s test, known hemolytic disease, or elevated ETCO.
  • Gestational age 35-36 weeks
  • Prior sibling had phototherapy
  • Cephalohematoma or bruising
  • Exclusive breastfeeding, esp. with poor feeding or weight loss
  • East Asian Race

Neurotoxicity Risk Factors

Neurotoxicity level is the bilirubin level at which brain damage is expected.

  • Isoimmune Hemolytic Disease
  • G6PD deficiency, G6PD test is needed with CBC test.
  • Asphyxia
  • Significant lethargy
  • Temperature instability
  • Sepsis, recommended for blood culture and PCR test for specific microbes.
  • Acidosis, observed through ABG test and serum electrolytes test.
  • Albumin less than 3.0 g/dL

How to get rid of jaundice in newborn babies?

According to AAP Phototherapy Guidelines (2004)

  • Lower Neurotoxicity Risk Level is when baby born at more than or equal to 38 weeks and well, doesn’t need to start phototherapy until reaches an approximate threshold 11.7 mg/dl at 24 hours of age.
  • Medium Neurotoxicity Risk Level is when baby born at 38 weeks with neurotoxicity risk factors OR 35 to 37 6/7 weeks and well, start phototherapy when reaches approximate threshold 9.9 mg/dl at 24 hours of age.
  • Higher Neurotoxicity Risk Level is when baby born 35 to 37 6/7 weeks and neurotoxicity risk factors, bilirubin level reaches an approximate threshold 8 mg/dl at 24 hours of age, recommended to start phototherapy.

Which bilirubin level needs incubator phototherapy or at home?

  • Home phototherapy is effective when TSB levels 2-3 mg/dl (35-50 µmol/L), or when there are no risk factors with elevated bilirubin levels in normal born babies.
  • Hospital phototherapy at a specialized incubator are more recommended than the home therapy solutions especially with those preterm newborns with risk factors.

Please read the previous explanation about normal newborn bilirubin levels.
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33 drugs cause high liver enzymes and liver pain

What drugs cause abnormal high liver enzymes count in blood test results, get to know them may help you and your children heal faster and live healthier, many medications can be responsible for mild to moderate increase in the liver enzyme tests.
liver function tests include ALT and AST which have a medical term of liver enzymes as they’re more frequently requested, in addition to ALK, Bilirubin, Gamma GT test, Albumin, and total protein test.
lft test is a short lab term for liver function test.
Liver pain is often confused with kidney pain, abdominal pain, or back pain because of its location. Liver pain is felt in the upper-right quadrant beneath your rib cage. It is usually felt as an ache that is dull, or the pains can be sharp and can sometimes be accompanied by back/shoulder pain.
Causes of Liver Pain

  1. Acetaminophen toxicity
  2. Alcoholic liver disease
  3. Primary liver cancer
  4. Liver cirrhosis
  5. Liver cysts
  6. Liver fibrosis
  7. Hepatitis
  8. PSC (Primary sclerosing cholangitis)
  9. The fatty liver disease: Victims usually have diabetes, pre-diabetes, high cholesterol and triglycerides. Other causes include:
    • Medications
    • Inherited or autoimmune liver disease
    • Malnutrition
    • Rapid weight loss
    • Viral hepatitis

Signs include fatigue, liver failure, loss of appetite, nausea, weight loss, weakness, jaundice, cola colored urine and fluid in the abdominal cavity among others. Treatment involves eating balanced meals, increasing physical activity and exercising. Staying away from unnecessary medication also speeds up the healing process. In severe cases, liver transplant may be recommended.drugs cause high liver enzymes liver pain
Examples of some of the common medications with potential liver toxicity include:
Pain relief medications such as:
acetaminophen (Tylenol and others),
ibuprofen (Advil, Motrin),
naproxen (Naprosyn, Naprelan, Anaprox, Aleve),
diclofenac (Voltaren, Cataflam, Voltaren-XR), and
phenylbutazone (Butazolidine)
Anti-seizure medications such as:
phenytoin (Dilantin),
valproic acid (Depakote, Depakote ER, Depakene, Depacon),
carbamazepine (Tegretol, Tegretol XR, Equertro), and
Antibiotics such as:
tetracyclines, (for example, tetracycline [Achromycin])
isoniazid (INH) (Nydrazid, Laniazid)
sulfamethoxazole (Gantanol),
trimethoprim (Trimpex; Proloprim, Primsol)
nitrofurantoin (Macrodantin; Furadantin; Macrobid),
fluconazole (Diflucan ) and some other anti-fungals, etc.
Cholesterol lowering drugs such as statins:
lovastatin (Mevacor, Altocor),
pravastatin (Pravachol),
atorvastatin (Lipitor),
fluvastatin (Lescol),
simvastatin (Zocor),
rosuvastatin (Crestor), and
Lowering cholesterol by drugs cause high liver enzymes and many studies revealed that lowering low cholesterol isn’t a good solution for many people with unstable essential oil ratios.
Cardiovascular drugs such as:
amiodarone (Cordarone),
hydralazine (Apresoline)
quinidine (Quinaglute, Quinidex), etc.
Other drugs
Antidepressant drugs of the tricyclic type
With drug-induced liver enzyme abnormalities, the high liver enzymes usually normalize weeks to months after stopping the medications. Typically, the physician will want to monitor the patient’s liver enzymes over time to confirm that the values are normalizing.
Finally, it’s good to know that: Although the overuse of harmful drugs to the liver does not cause complete destruction of the liver, but expose your liver to many health risks including pain between the ribs and fatty liver.

A Blood Test For Liver Function Evaluation with References

If you are looking for a blood test for liver function evaluation, Actually there are 8 tests for liver function testing.
I must explain that liver is a principal organ, many biological process are controlled and managed by liver cells, so hat the liver status can be monitored by many methods and tests.
Take LFTs when you are checking for the liver working status, General checkup in wellness and illness, checkup in pregnancy, and for checking up almost any pain such as Heartburn and difficult urination.
In liver function panel tests we use the chemical substance, “usually enzymes” which synthesized or managed by the liver to check how well he liver cells are working.

A panel of tests used to evaluate liver function. Includes:
Alanine aminotransferase (ALT)
Alkaline phosphatase (ALP)
Aspartate aminotransferase (AST)
Total protein

Liver enzyme testing for General checkup includes ALT, AST, alkaline phosphatase;
Very Specific liver function tests (LFTs) include PT, INR, albumin, and bilirubin.
Used in the evaluation of symptoms associated with liver disease (jaundice, nausea, vomiting and/or diarrhea; loss of appetite;
ascites, hematemesis, melena; fatigue or loss of stamina; history of alcohol or drug abuse).

Who have impaired Liver function and needs for testing?
Persons on a certain medication or a taking pills which cause a shot in their liver test results
Patients with acute or chronic liver illness
Who have signs like Abdominal pain, nausea and vomiting, or yellow skin
Addicts to Alcohols or abuse drugs.
Also Liver enzymes are very sensitive to irritability, allergic reactions, and constipation as well.

Step by step testing for Liver illness and High Enzymes:
AST and ALT is the main tests to assess liver function evaluation in most cases of liver diseases as hepatic inflammation due to viruses, alcohols, and others.
When results come up with elevation in one or both enzymes, more medical tests must be taken for further diagnosis.
Such tests including:
Liver viruses tests: HCV-Ab, HBs-Ag, and HAV-IgM test for Children.
If there is a yellow discoloration of the skin and urine, take a “Bilrubin test”.
If Bilirubin is normal, its ok, if high bilirubin results are shown, then take these tests: Alkaline phosphatase
5′ nucleotidase, or Gamma-glutamyl transpeptidase (GGT), these tests re specific for assess biliary ducts and bile function.
Ultrasound and CT scan to evaluate Liver stones or accumulated fats on the liver which referred as “Fatty Liver”.
If Stones are shown in Scan results, then you must go for urine test and further blood investigations,
If Fats are shown, you must take a fasting blood sample for cholesterol and triglycerides tests.
If Viral testing and Scan show up negative results, take more tests as Alkaline phosphatse and CPK enzymes for assess in bones and muscles issues respectively.
If All results come up Normal, then we may consider the raise in liver enzymes of a transient cause such as Constipation or even unmentioned medication by he patient.

Normal Range and References of main Liver Function Tests:
Alanine aminotransferase (ALT)
10–35 U/L; SI units: 0–0.58 mkat/L
■ Enzyme found in liver cells exclusively.
■ Used in diagnosis of liver, biliary, and pancreatic disease.

Aspartate Aminotransferase (AST)
Adult, child: 0–35 U/L; SI units: 0–0.58 kat/L
Newborn: 15–60 U/L
■ Enzyme found in cardiac muscle, liver, and skeletal muscle.
■ Used primarily to evaluate patients with symptoms of liver disease (jaundice, liver enlargement, fatigue, weight loss, ascites, etc.).

Adult: 3.5–5 g/dL; SI units: 35–50 g/L
Child: 3.8–5.4 g/dL; SI units: 38–54 g/L
■ Main plasma protein; helps maintain osmotic pressure. Decreased albumin causes fluid shifts and resultant edema.
■ Levels decrease in renal or hepatic disease, acute infection,malnutrition, malignancy, diabetes, and many other chronic and acute conditions.

Bilirubin,Total, Direct, Indirect
Adult, child: Total: 0.3–1 mg/dL; SI units: 1.7–20.5 mol/L
Direct: 0.1–0.3 mg/dL; SI units: 1.7–5.1 mol/L
Indirect: 0.1–0.8 mg/dL; SI units: 1.7–12 mol/L
Newborn: 1–12 mg/dL; SI units: 17.1–205 mol/L
Critical Level: Newborn: 15 mg/dL; SI units: 257 mol/L
Bilirubin is a by-product of the the breakdown of hemoglobin.
■ Most bilirubin is chemically attached (conjugated) to another substance. This is called direct bilirubin.  Unconjugated builirubin is called indirect bilirubin. Conjugated bilirubin is excreted in bile.
■ High bilirubin levels cause jaundice and are seen in liver disease and biliary obstruction.
■ In newborns, elevated bilirubin occurs with Rh or ABO incompatibility. Brain jaundice (kernicterus) develops at higher levels and can result in mental retardation, cerebal palsy, or blindness.

Alkaline Phosphatase (ALP)
Adult: 42–136 U/L
Child: 50–230 U/L
■ Enzyme found predominately in the liver, biliary tract, and bone.
■ Useful in assessing liver and bone disease.
■ ALP isoenzymes distinguish between liver and bone disease. ALP1 is hepatic; ALP2 is from bone.

I have to mention some recommendation, the previous explanation is valid if you wan to go for general check up then such information will guide you, if you’re suffering from an illness or unknown pain please book an appointment and get you examined by  a professional doctor.