Bilirubin (B) is a toxic chemical compound formed during the utilization of red blood cells. His disposal is engaged in the liver. The process protects the whole body from poisoning and especially the brain. Increased level B is an indicator of the disorder of pigment metabolism and liver enzymes.
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What is bilirubin
The source of bile pigment is heme, the iron-containing part of the transport protein of the blood. Aging red blood cells are the main suppliers of B. Every day, 1% of their total number disintegrates to form 300 mg of a yellow-brown substance. In portal veins, it enters the liver, where it changes properties: it becomes water soluble, loses toxicity. With bile it turns out in the intestine, staining the stool. The part passes through the kidneys and is excreted in the urine. A healthy body contains at least B, so there is no toxic effect on its part.
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Norm bilirubin in the blood
Biochemical analysis is performed on an empty stomach. Biomaterial taken from a vein. A day before the procedure, you must refrain from fat and alcohol. Results affect:
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- Herbs choleretic action.
- Hard diet or overeating.
- Medications that affect blood coagulation.
The analysis on B is shown under the following conditions:
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- Hemolytic and gallstone disease.
- Inflammation of the pancreas.
- Determination of the liver.
- Control of the treatment.
Table. Norm B in adults, the same in men and women.
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|Type of hyperbilirubinemia||Level (µmol / l)|
The diagnostic value of the analysis by definition of bilirubin is the higher, the earlier it is performed and correctly evaluated, in terms of finding out deviations from the norm.
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Direct and indirect bilirubin
The following pigment fractions are distinguished:
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- Indirect (unbound) - water-insoluble toxic compound, easily penetrating through the plasma membrane. The reticulo-endothelial system (RES) is responsible for the synthesis, where the heme is transformed. Then the bile pimento is combined with albumin and transported to the liver.
- Straightafter neutralization in hepatocytes. In the form of sterkobilina displayed with feces.
Total bilirubin is the sum of the two previous ones, respectively.. If it is within acceptable limits, then further research to determine the level of individual factions is inappropriate.
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Hyperbilirubinemia is a concentration of B, exceeding the norm. With rates of 36 µmol / l, the scleral and skin yellowness is manifested. An increase ten times threatens the health and even human life.
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What increases the level of bilirubin in the blood
The massive destruction of red blood cells increases the proportion of unconjugated pigment. The liver is not able to neutralize such a quantity of it, so the concentration of B in the plasma increases. These changes occur with hemolytic anemia (anemia) - pathologies in which the formation and maturation of red blood cells are disrupted. Provocateurs can be environmental factors, including:
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- diseases like malaria.
Anemia may be congenital, then the activity of the enzyme system in the erythrocytes decreases or the cell membranes are defective.
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Elevated blood bilirubin is sometimes associated with inadequate intake of vitamin B12.
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The B metabolism is disturbed in chronic liver diseases, the alcoholic lesion of hepatocytes as a result of which the pigment goes into the blood. In Gilbert's syndrome, there is a deficiency of glucuronyltransferase, an enzyme involved in pigment metabolism.
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Symptoms of elevated bilirubin
When associated with hemolytic anemia, the condition is accompanied by the following symptoms:
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- Lag in physical development in children.
- Fast fatiguability.
- Enlarged spleen.
- Severity in the left hypochondrium after exercise.
The yellowness of the skin and mucous membranes develops gradually: from the sclera and the oral cavity to the face, palms, feet and throughout the body. Its degree depends on the individual characteristics of a person, for example, in complete staining is less intense compared to thin ones. The following symptoms speak about liver pathologies:
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- Colorless or too light stools.
- Dark urine.
- Bitterness in the mouth.
The disturbed outflow of bile is a consequence of gallstone disease, tumor and inflammatory processes.
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What is dangerous condition
Bile pigment is toxic. The brain is especially sensitive to it. Other organs are able to work normally even in conditions of its high level. How long this activity will be depends on the degree of hyperbilirubinemia:
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- Slight with indicators of 50 - 70 micromol / l. Not accompanied by toxic organ damage. Requires clarifying the reasons for the increase.
- Pronounced (150-170). Danger is present, but it is uncritical. With a long existence causes poisoning of the body, which is unacceptable and should be quickly eliminated.
- Heavy (300). In an adult, this means that there is a pronounced intoxication that carries a threat to the life of the patient.
- Extremely heavy. Without medical care a person dies.
The consequences of hyperbilirubinemia are:
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- Liver failure.
- Hypovitaminosis, as a result of disorders in the digestive tract.
Which doctor and when to contact
The first signs of increased bilirubin - A reason to visit a gastroenterologist. In case of blood diseases, the patient will receive a referral to a hematologist. The surgeon's help may also be necessary if obstructive jaundice is a consequence of gallstone disease. But we must not forget that mild yellowness may be a sign of hypothyroidism or diabetes. Sometimes it is the result of consuming foods high in carotene. If necessary, the infectious disease specialist will deal with the treatment of viral hepatitis, oncologist with malignant tumors, and the hepatologist with liver diseases.
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How to reduce bilirubin in the blood
Hyperbilirubinemia is not an independent pathology requiring specific therapy. But the icteric staining of mucous membranes and skin is a reason for going to the doctor. Attempts to independently cope with the problem until the moment of clarification of the cause of high bilirubin is unacceptable
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Only a doctor after a timely examination will find out the etiology of the condition, make a diagnosis, prescribe adequate treatment, sometimes difficult surgery. In case of toxic liver damage, infectious hepatitis, hospitalization and the introduction of detoxification compositions will be required.
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If total bilirubin is elevated, and the reason is associated with a violation of bile outflow, then appropriate medications are prescribed:
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All of them, along with hepatoprotectors, help cleanse and heal the liver, as well as its normal work. To reduce the load on the gland prescribed enzyme preparations:
To get rid of toxins are shown absorbing agents:
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- Activated carbon.
In case of serious diseases of infectious nature, antiviral compounds will be needed, as well as immunomodulators. Antioxidants eliminate the damaging effect of toxins. Barbiturate-based drugs will lower B.
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Acceptance of lipoic, ascorbic, folic acid, vitamins of group B with long courses will help restore the functioning of the alimentary canal.
The introduction of solutions of protein, hemodeza, glucose while taking diuretic compounds allows you to accelerate the release of bilirubin tissues and reduce its toxic effect. Any appointments are made only by a doctor.
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Highly effective method to translate toxic bilirubin in direct under the influence of various artificial light sources. Procedures to take in strict accordance with the instructions for portable dichroic, fluorescent and other lamps (protect eyes). In the absence of equipment it is useful to take sun baths, preferably in the morning and in the evening for 15 minutes. In the cold season to take walks in the scattered sunlight.
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With a mild degree of hyperbilirubinemia that does not require urgent hospitalization, you can use alternative medicine recipes. They are unable to cope with the problem on their own, but they complement outpatient medical therapy.
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To improve bile formation, yarrow, dogrose, chicory are used, and oregano, dandelion, chamomile, and mint are used for outflow. Some herbs, such as milk thistle and tansy, have all these properties. It is useful to drink freshly prepared beet juice (a third of a glass before a meal), as well as a decoction of calendula.
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The liver will respond favorably to the recipe tinctures of 1 tbsp. l dry birch leaves and 250 ml of boiling water. To sustain half an hour, to drink for the night. The composition will soothe and remove toxins from the liver, including free bilirubin. A recipe based on corn stigmas is prepared according to the same recipe. Take 2 times a day for 125 ml. Tea with mint will quickly clear the liver, not only for an adult, but also for a child. You can drink for 2 months without a break.
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The condition of the liver will improve if:
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- Eat fractional, small portions.
- Abandon heavy food.
- Include in the menu products with a high content of pectin, fiber.
- Drink more non-carbonated water.
- Minimize the amount of salt.
- More often eat porridge.
- Steam or boil.
- Do not get involved in spicy, fatty dishes.
Reduce bilirubin products from the following list:
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- Herbal teas.
- Vegetable, milk soups.
- Lean meat.
- Kefir, cottage cheese.
- Egg white.
As for fruits, they should be ripe.
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Bilirubin level will remain within the normal range if:
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- In time to identify and treat anemia, alcohol poisoning, infectious diseases, liver disease, as well as the gallbladder.
- Limit psycho-emotional, physical exertion.
- Eat well. Give up alcohol, smoking.
- Take medications as prescribed by specialists, follow the instructions, dosages.
Why does total bilirubin increase in an adult?
The enzyme is an important indicator of the functional activity of several body systems simultaneously. For an adult, 5.2–17 mmol / l is total bilirubin, 3.5–12 mmol / l is indirect and 1.8–5.2 mmol / l is direct bilirubin.
The substance is excreted by the body through feces - it is the liver enzyme that gives stool a specific shade.
A significant increase in the hepatic substance bilirubin in the blood is due to an increase in the intensity of the destruction of red blood cells. Damage to the liver tissue causes a violation of its excretory function. As a result, the flow of bile occurs in the intestinal tract, which is a beneficial condition for the development of many diseases.
There are a number of diseases during the progression of which in humans increases liver enzymes in the blood.
- Congenital or acquired anemia. The disease is characterized by the accumulation of indirect type bilirubin. This occurs due to accelerated hemolysis of red blood cells. Hemolytic anemia of acquired origin develops as a complication of autoimmune diseases (rheumatoid arthritis, systemic lupus erythematosus), as well as against the background of infectious lesions - for example, malaria, sepsis.
- Disruption of the production of bilirubin direct type in the liver. It occurs with hepatitis, tumor process, cirrhosis and some other diseases. Also, an increase in the level of the liver enzyme is capable of leading to Gilbert's syndrome - a disease of hereditary origin characterized by impaired bilirubin production. To establish the cause of the help of auxiliary types of research.
- Problems with the functioning of the gallbladder. With impaired bile flow, the amount of direct bilirubin always increases.
- Acceptance of certain pharmacological groups of drugs has in the list of its side effects a violation of the excretory function of the liver. These medications include hormonal substances, drugs administered for the purpose of chemotherapy, anti-inflammatory nonsteroidal analgesics.
- Worm infestation.
There are a lot of root causes for the increase in total bilirubin, and since the spectrum is wide, it is necessary to first determine what was the basis for this circumstance.
Symptoms of elevated bilirubin
It is quite simple to suspect an increase in the level of bilirubin in an adult: this can be done without laboratory blood tests, and the analysis performed will only confirm the preliminary diagnosis.
The main symptoms of an elevated liver enzyme in an adult will be the following:
- dyspeptic disorders (nausea, unpleasant taste in the mouth, especially in the morning),
- gray or white viscous coating on the tongue,
- itching of the skin,
- increased fatigue
- severe yellowness of the skin and mucous membranes,
- dark color of urine, colorless feces,
- discomfort in the right hypochondrium due to the increased size of the liver, fatty and heavy food causes discomfort, belching, and sometimes - heartburn or upset stool.
If the increase in bilirubin occurred against the background of hepatitis of viral genesis, an increase in body temperature to high numbers will be an indispensable symptom.
To establish what is the cause of the deterioration of health, initially must the therapist. Examination reveals changes in the color of the sclera and skin, the presence of a viscous plaque on the tongue, and an enlarged liver, which can be palpated, since the organ with inflammation has quite clearly defined contours.
If it is confirmed that the problem consists precisely in liver disease, the patient is referred to a gastroenterologist or infectious disease specialist. If, at the time of treatment, an oncologist is already aware of the progressive tumor process. They prescribe a biochemical blood test to determine the level of direct and indirect bilirubin, as well as AST and ALT (liver function tests).
Additionally, liver ultrasound is performed - this will allow visualization of the state of the parenchyma, biliary ducts, the outlines of the organ and its location.
Assign performance of a comprehensive clinical blood test - in this way the doctor will be able to understand the exact picture of the state of the body: leukocytosis indicates the presence of inflammation, while a low concentration of hemoglobin will indicate the development of anemia. A therapeutic approach can be planned only on the basis of a thorough history of the patient’s state of health and the maximum information obtained through laboratory and auxiliary diagnostics.
Increased total bilirubin: treatment
To reduce the concentration of bilirubin is impossible without eliminating the underlying disease. Curing the root cause, it is possible to normalize the level of the blood enzyme. Only a therapist or an infectious diseases specialist should plan the treatment approach, depending on the underlying ailment. Each of the methods of treatment has indications, contraindications and a wide range of possible side effects. A person without proper education can harm himself by experimenting with drugs and procedures. The main ways of reducing the level of bilirubin are reduced to the following aspects:
- Infusion therapy. The doctor prescribes an intravenous drip of saline and glucose. The goal is to remove intoxication, cleanse the body of excess bilirubin and residual metabolic products. This measure is effective and serves as an alternative option for diseases that provoke a serious condition of a person.
- Phototherapy The essence of the technique consists in irradiating the patient with special lamps. Under the influence of their rays, indirect bilirubin is converted into a direct, unrestrictedly eliminated from the body. The technique is effective and helps to normalize the blood condition of even newborns, which also serves as an argument in favor of its use among adult patients.
- Prescribe medications that normalize the process of removing bile. Simultaneously with them, prescribed drugs that promote detoxification. The most common of these is activated carbon.
- During treatment, the doctor prescribes nutrition correction. This is another way to reduce bilirubin in the blood. The load on the liver is reduced due to the rejection of fried foods, the use of carbonated sugary drinks, spices.
- If the level of bilirubin is due to the development of hepatitis, the main therapeutic actions are aimed at eliminating the virus. Also, the patient is prescribed medicines that have a liver protective effect on the liver. Elimination of hepatitis can be determined by indicators of biochemical analysis of blood: the level of bilirubin will be the norm.
- Gilbert's syndrome and some pathologies associated with impaired liver activity are treated with Phenobarbital. Only a doctor should prescribe this drug, since the risk of complications is high if the direction of treatment is incorrect.
- If the primary cause of the disease is an inflammatory process caused by infection of the liver, hepatoprotectors will be key drugs. It is important to ensure the introduction of antiviral, antibacterial, immunomodulatory agents into the body.
There is also a mass of traditional medicine - decoctions, infusions, but the appropriateness and safety of their use should be discussed with your doctor. Some of the medicinal herbs and plants have side effects, among them - increased heart rate, nausea, vomiting, impaired consciousness, weakness, drowsiness. In combination with the main disease, it is not always appropriate to implement recipes of traditional medicine - this can distort the actual clinical picture.
The volume of bilirubin in the blood is determined by how fully all segments of the chain of production, exchange and elimination of bilirubin from the body function. The process of purification from the final products of decay must occur consistently, not spontaneously, fully, without failures at any stage. To assess this will help laboratory analysis. Otherwise, it is impossible to identify an increase in the concentration of the hepatic enzyme, make a diagnosis and begin treatment. It is unsafe to ignore the signs of excessive bilirubin content: an urgent need to seek qualified assistance.
The main stages of bilirubin metabolism
So, with the destruction of red blood cells formed bilirubin, which is a toxic and water-insoluble compound. Its further transformation occurs in several stages:
- With blood flow, bilirubin is transferred to the liver - this requires a carrier, in the role of which albumin protein acts, which quickly and firmly binds toxic bilirubin in the blood plasma. This protein-bilirubin complex is not able to penetrate the renal filter, and therefore does not enter the urine,
- penetration of bilirubin into the hepatic cell after its separation from albumin on the surface of the hepatocyte membrane and further transportation through the membranes of the endoplasmic reticulum,
- conjugation (binding) of bilirubin with glucuronic acid in the endoplasmic reticulum and the formation of bilirubin-diglucuronide. It is in this bound state that bilirubin becomes soluble in water and, thus, can be excreted with bile and urine from the body,
- excretion (elimination) with bile - the final stage of the exchange of bilirubin, which in the intestine turns into urobilinogen and excreted as stercobilinogen with feces. A small amount of bilirubin is absorbed by the intestinal wall and, entering the bloodstream, is filtered by the kidneys and excreted in the urine.
Signs of elevated bilirubin
As is known, the primary role in the metabolism of bilirubin belongs to the liver, and jaundice is a characteristic syndrome, reflecting its damage and also manifested in cases when the amount of bilirubin exceeds the functional ability of the liver to bind its excess, or there are obstacles in the way of bile outflow and, accordingly, elimination of conjugated bilirubin from the body.
Sometimes it happens that the severity of jaundice does not match the serum bilirubin figures. For example, in obesity, edema, yellowness is less noticeable, while in lean and muscular people it is more pronounced.
The causes of high bilirubin in the blood are very diverse and are associated either with its enhanced formation in the cells of the reticuloendothelial system, or with a violation in one or several links of metabolism in the hepato-biliary system.
From a clinical point of view, it is important to note that the degree of hyperbilirubinemia affects the nature of staining of various tissues:
- So, most often the first to get the icteric tinge of the sclera
- Oral mucosa
- Then the face, palms, soles turn yellow, and finally all skin
It must be remembered that yellow staining of the skin is not always the result of hyperbilirubinemia. For example, when eating food containing a large amount of carotene (carrots, tomatoes), diabetes, hypothyroidism (reducing thyroid function), the skin may become yellow, but in these cases the sclera will be normal (intact).
List of diseases accompanied by high levels of bilirubin in the blood
Diseases in which direct bilirubin is elevated:
- Acute viral hepatitis (hepatitis A, B, hepatitis with infectious mononucleosis)
- Chronic hepatitis (hepatitis C), autoimmune hepatitis
- Bacterial hepatitis (brucellosis, leptospirosis)
- Toxic (poisoning by toxic compounds, fungi), drugs (taking hormonal contraceptives, NSAIDs, anti-tuberculosis, anticancer drugs)
- Pregnant jaundice
- Liver tumors
- Biliary cirrhosis
- Hereditary jaundice - Rotor syndrome, Dabin-Johnson
Diseases for which indirect bilirubin rises:
- Congenital hemolytic anemias - spherocytic, non-spherocytic, sickle-cell, thlasemia, Markyavai-Michele disease
- Acquired hemolytic anemia autoimmune - develops on the background of systemic lupus erythematosus (symptoms, treatment), rheumatoid arthritis, lymphocytic leukemia, lymphoid granulomatosis (symptoms, treatment), etc.
- Infectious diseases - typhoid fever, sepsis, malaria
- Drug hemolytic anemia - triggered by taking cephalosporins, insulin, aspirin, NSAIDs, chloramphenicol, penicillin, levofloxacin, etc.
- Toxic hemolytic anemia - poisoning with poisons, insect bites, snakes, mushroom poisoning, lead, arsenic, copper salts (copper sulfate)
- Syndromes of Gilbert, Crigler-Nayar, Lucy-Driscol.
Erythrocyte destruction (accelerated or increased)
High indirect bilirubin in hemolytic jaundice is due to increased red blood cell disintegration (hemolysis), which may be due not only to hereditary defects of red blood cells themselves (sickle cell anemia, spherocytosis), but also a number of external causes, for example:
- infections (malaria, sepsis, typhoid fever, mycoplasmosis),
- poisoning by hemolytic poisons of various origin (toadstools toxoid, mercury, lead, snake venom others),
- blood transfusion incompatible by group or rhesus factor
- malignant tumors, in particular, hematopoietic tissue (leukemia, myeloma, etc.),
- massive hemorrhages (lung infarction, extensive hematomas).
Hemolytic jaundice has the following symptoms:
- lemon yellow staining of the skin and mucous membranes, sclera of the eyes
- pallor due to anemia due to increased red blood cell destruction
- pain in the left hypochondrium due to an enlarged spleen
- possible increase in body temperature
- a large amount of sterko- and urobilin is found in the feces and urine, giving them dark staining
- against the background of lack of oxygen in the tissues of the body, a person can have heartbeat, headaches, fatigue
Disruption of the normal flow of bile
Subhepatic jaundice develops when the conjugated bilirubin is re-injected into the blood due to a violation of its outflow with bile, most often caused by cholelithiasis, acute and chronic pancreatitis, aneurysm of the hepatic artery, cancer of the pancreas or gall bladder, and duodenal ulcers, diverticulae duodenum. In this condition, high direct bilirubin in the blood. The causes of this type of jaundice can be:
- bile duct closure with stone, tumor, parasites,
- compression of the bile ducts from the outside, accompanying tumors of the gallbladder, pancreatic head, lymph node enlargement,
- inflammatory processes in the biliary ducts with their subsequent sclerosis and narrowing of the lumen,
- congenital anomalies or underdevelopment of the bile ducts.
For this type of hyperbilirubinemia (with stones in the gall bladder, cancer of the gall or pancreas) is characterized by:
- the strongest icteric staining of the skin
- most patients complain of pruritus, which results in scratching of the skin
- since the binding function of the liver is not impaired in this case, an increased amount of conjugated bilirubin will be detected in the blood
- unlike other types of jaundice, fecal masses will be acholichny, that is, have almost white color, which is due to the lack of stercobilin in them, and dark color urine
- there are periodic pains in the right hypochondrium or an attack of such pain in case of hepatic colic
- violation of the digestive tract - flatulence (causes, treatment), diarrhea, constipation, nausea, loss of appetite, belching bitter
Violations that occur in the hepatic stage of exchange of bilirubin (binding, transport in the liver cell and removal from it), cause the occurrence of hereditary jaundice:
- kriegler-nayar syndrome
- Gilbert's syndrome
- Dabin-Johnson syndrome
Gilbert's syndrome, a benignly flowing hyperbilirubinemia with a favorable prognosis, is most common.
The causes of high bilirubin in the blood of this disease lie in the lack of the liver cell enzyme that binds free bilirubin to glucuronic acid, therefore hyperbilirubinemia will be mainly due to its unbound fraction.
The disease is hereditary and is accompanied by a defect in the genes located in the second chromosome. The prevalence of Gilbert syndrome in the world varies. So, in Europeans it occurs in 3-5% of cases, while in Africans it is in 36%, which is associated with a high frequency of occurrence of a characteristic genetic defect in them.
Often the disease is asymptomatic or with episodes of jaundice of varying intensity, which occur during stresses, excessive physical exertion, while taking alcohol. Given the benign course and favorable prognosis, specific treatment in such patients, as a rule, is not required.
Suprahepatic jaundice occurs when the amount of newly formed bilirubin is so large that even the intensity of its binding by the liver 3-4 times stronger does not lead to the removal of excess blood serum.
Hepatic, or parenchymal, jaundice occurs as a manifestation of various diseases involving damage to the liver parenchyma and biliary capillaries, which leads to a violation of the capture, conjugation and excretion of bilirubin, as well as its reverse flow into the blood from the bile ducts during cholestasis (bile stasis) inside the liver . It is one of the most frequently developing types of jaundice, with high direct bilirubin.
Diseases accompanied by hepatic jaundice are many and varied, but most often this type of hyperbilirubinemia is observed in hepatitis and cirrhosis of the liver.
Hepatitis are a large group of inflammatory liver lesions that may be viral in nature or caused by non-infectious agents (drug hepatitis, autoimmune, alcohol).
In the acute course of the disease, a viral infection (hepatitis A, B, C, D, G) most often acts as a causative factor, and the manifestations include:
- signs of general intoxication with increasing body temperature
- common weakness
- muscle and joint pain
- in this case, the pain in the right hypochondrium will indicate
- icteric staining of skin and mucous membranes
- discoloration of feces and urine, as well as characteristic changes in laboratory parameters
With the progression of the disease with the involvement of a significant amount of hepatic parenchyma, as well as with a difficult flow of bile, itching, bleeding, signs of brain damage in the form of characteristic hepatic encephalopathy and, ultimately, the development of hepatic-renal failure, which represents a threat to life and often the cause of death of such patients.
Chronic hepatitis is quite common as a result of acute viral, drug, and alcoholic liver damage. Their clinical manifestations are reduced to parenchymal jaundice and changes in the biochemical analysis of blood, with an exacerbation fever, arthralgia, and skin rashes are possible.
Cirrhosis of the liver These are severe changes with the loss of the normal histoarchitecture of its parenchyma. In other words, there is a violation of the normal microscopic structure: as a result of the death of hepatocytes, the hepatic lobes disappear, the orientation of the blood vessels and bile capillaries is disturbed, and massive foci of connective tissue appear at the site of damaged and dead cells.
These processes make it impossible for the liver to perform the functions of binding and removing bilirubin from the body, as well as the processes of detoxification, the formation of various proteins and blood coagulation factors. Most often, cirrhosis of the liver completes its inflammatory lesions (hepatitis).
In addition to parenchymal jaundice, clinical manifestations characteristic of cirrhosis will include an enlarged liver and spleen, pruritus, fluid in the abdominal cavity (ascites), varicose veins of the esophagus, rectum, anterior abdominal wall.
Over time, signs of liver failure increase, brain damage develops, blood clotting decreases, and this is accompanied not only by rashes on the skin, but also hemorrhages in the internal organs and bleeding (stomach, nasal, uterine), often life-threatening.
Elevated bilirubin in newborns
Special attention should be paid to hyperbilirubinemia, that is, increased bilirubin in newborns. It is known that in the first days of life, most babies have some degree of jaundice, which is physiological in nature.
This happens because the child's body adapts to the extrauterine existence, and the so-called fetal (fetal) hemoglobin is replaced by the hemoglobin of the “adult” type, which is accompanied by partial destruction of red blood cells. As a rule, the peak of yellowing is noted on 3-5 days of life, and after a short time it is resolved, without bringing harm to the child’s body.
In cases where hemolysis occurs in premature babies, either due to Rh-conflict or other causes, a significant increase in the unbound fraction of bilirubin can occur with its penetration through the hemato-encephalic barrier.
The result will be the development of so-called nuclear jaundice, in which the brain nuclei are damaged, which represents a threat to the life of the baby and requires immediate intensive therapy.
In all cases, it is necessary to accurately establish the causes of high bilirubin in a newborn, in order to avoid serious complications with timely treatment:
- physiological breakdown of red blood cells
- liver damage
- congenital anomalies of biliary tract
- rhesus conflict, etc.
How to reduce bilirubin?
Ways to combat hyperbilirubinemia depend on the reasons that caused it, however, when jaundice appears, it is not worth self-treatment, but you should immediately consult a doctor. Since jaundice is only a symptom and treatment should be primarily aimed at eliminating its causes.
At high numbers of bilirubin due to pronounced hemolysis of erythrocytes, infusion therapy with the introduction of glucose, albumin, as well as plasmapheresis is indicated. In jaundice of newborns, phototherapy is very effective, in which the irradiation of the skin contributes to the conversion of free toxic bilirubin into bound, easily removed from the body.
With non-conjugation hyperbilirubinemia, administration of drugs that enhance the activity of liver enzymes, such as phenobarbital, is effective.
In all cases, it should be remembered that jaundice is usually an indicator of serious disorders in the body, and therefore, timely identification of its causes increases the likelihood of a favorable outcome and, possibly, a full recovery from the disease that caused it. Do not neglect the visit to the doctor even in the case of a slight yellow staining of the skin, sclera, because timely diagnosis and timely treatment started are not only able to save the life of the patient, but also significantly improve its quality.
Bilirubin metabolism is a complex chemical process that is constantly occurring in our body, when it is disturbed at any stage, and a change in the level of this substance in the blood serum appears. Therefore, bilirubin is an important indicator of the work of several body systems at once.
Depending on the type, direct and indirect bilirubin is isolated.
- Indirect - the one that is formed as a result of the breakdown of hemoglobin. Soluble in fats only, therefore, is considered very toxic. He is able to easily penetrate into the cells, thereby violating their functions.
- Direct - the one that is formed in the liver. It is water soluble, therefore, is considered less toxic. Direct bilirubin is eliminated from the body along with bile.
Direct bilirubin is safe for the body, since it was previously neutralized by liver enzymes. Such a substance quietly leaves the body and does not cause any harm. The bilirubin of the indirect species is very toxic, it was recently formed from hemoglobin and is not bound by liver enzymes.
Total bilirubin increased - what does it mean in an adult?
What are the reasons why in adults the amount of total bilirubin in the blood increases, and what does this mean? What factors contribute to this?
In adults, there are a number of main reasons:
- accelerated decomposition of red blood cells
- primary biliary cirrhosis
- other conditions causing violations of the outflow of bile,
- helminth infections and parasites in the body,
- intrahepatic cholestasis,
- jaundice pregnant
- liver tumors
- violations of the production of enzymes responsible for the formation of direct bilirubin,
- viral, bacterial, toxic, medicinal, autoimmune and chronic hepatitis - with the liver becoming unable to remove bilirubin.
Depending on what kind of process is violated, an increase in one of the bilirubin fractions can be observed in the blood. If an increase in total bilirubin is detected with an even distribution of fractions, then this is most characteristic of liver diseases.
Causes of elevated direct bilirubin
The level of direct bilirubin in the blood increases due to violations of the outflow of bile. As a consequence, the bile is sent to the blood, not to the stomach. The reasons for this are most often the following pathologies:
- hepatitis of viral etiology in the acute form (hepatitis A, B, with infectious mononucleosis),
- bacterial etiology hepatitis (leptospirosis, brucellosis),
- chronic hepatitis,
- autoimmune hepatitis,
- drug-induced hepatitis (as a result of therapy with hormonal drugs, nonsteroidal anti-inflammatory drugs, anti-tumor and anti-tuberculosis drugs),
- toxic hepatitis (poisoning by fungal poisons, industrial toxic substances),
- cancer of the gallbladder, liver or pancreas,
- biliary cirrhosis,
- Rotor syndrome, Dabin-Johnson.
Preemptive increase in direct bilirubin. The basis is a violation of the outflow of bile.
Causes of elevated indirect bilirubin
Diseases for which indirect bilirubin rises:
- Syndromes of Gilbert, Crigler-Nayar, Lucy-Driscol.
- Infectious diseases - typhoid fever, sepsis, malaria.
- Congenital hemolytic anemias - spherocytic, non-spherocytic, sickle-cell, thlasemia, Markyavai-Michele disease.
- Toxic hemolytic anemia - poisoning by poison, insect bites, snakes, mushroom poisoning, lead, arsenic, copper salts (copper sulfate). Drug hemolytic anemia - triggered by taking cephalosporins, insulin, aspirin, NSAIDs, chloramphenicol, penicillin, levofloxacin, etc.
- Acquired hemolytic anemia autoimmune - develops on the background of systemic lupus erythematosus (symptoms, treatment), rheumatoid arthritis, lymphocytic leukemia, lymphoid granulomatosis (symptoms, treatment), etc.
Predominant increase in indirect bilirubin. The basis is the excessive destruction of red blood cell cells.
The liver is most important in the production of bilirubin. With the pathologies of this organ, the normal process of neutralizing free bilirubin and its transition to the direct state becomes impossible. Among the liver diseases in which the metabolism of bilirurin is disturbed, there is cirrhosis, hepatitis A, B, C, B and E, alcoholic and drug-induced hepatitis, liver cancer.
The level of both types of bilirubin increases, which is manifested by the following symptoms:
- discomfort and heaviness in the right side due to an enlarged liver,
- faded color of feces and dark - urine,
- nausea, belching after eating, especially strong discomfort from greasy and heavy food,
- fatigue, dizziness, apathy,
- increase in body temperature (with hepatitis viral nature).
May reveal other causes of increased bilirubin levels. These include a hereditary lack of liver enzymes, this pathology is called Gilbert's syndrome. In patients, the level of bilirubin in the blood is significantly increased, so the skin and eye sclera often have a yellow tint.
Bile outflow disturbance
In diseases of the biliary system, for example, gallstone disease, the patient usually exhibits the following symptoms:
- yellowness of the skin and sclera,
- pain in the right hypochondrium (with hepatic colic is very intense),
- abdominal distention, impaired stool (diarrhea or constipation),
- discoloration of feces and dark urine,
Unlike blood and liver diseases, in this situation the amount of direct (bound) bilirubin, which is already neutralized by the liver, increases.
The development of suprahepatic jaundice is due to increased destruction of red blood cells. This increases the predominantly free fraction. Among the diseases emit:
- hemolytic and B12-deficient anemias,
- extensive hematomas
- the impact of toxic substances on blood cells
- reaction to foreign blood transfusions or organ transplants,
In case of violation of the metabolism of bilirubin, its quantitative indicators in the bloodstream can become large. It is expressed by jaundice, or by staining mucous membranes and skin in yellow color.
- If the concentration of bile pigment in the serum reaches 85 µmol / l, then they say a slight form of increase.
- Jaundice is considered moderate with indicators of 86-169 µmol / l, severe - with numbers above 170 µmol / l.
Depending on the type of jaundice, its manifestations are different. Skin may have a bright yellow, green or saffron yellow shade. In addition, with increased bilirubin there is a darkening of the urine (it becomes the color of dark beer), severe itching of the skin.
Other signs may include:
- bitterness in the mouth
- dark urine
- white color of feces,
- general weakness
- impaired memory and intellectual abilities
- enlarged liver in size and heaviness in the right hypochondrium.
How to treat elevated bilirubin in the blood
To reduce bilirubin is possible only after establishing the cause of its increase. This means that you will have to pass tests for viral hepatitis, liver function tests (determination of astht activity, alkaline phosphatase, etc.), liver ultrasound, and more specific studies.
In this case, treatment in adults is mainly etiotropic, that is, affects the leading disease. For example, in violation of the patency of the biliary tract, it is necessary to perform the removal of stones or tumors, in some cases, duct stenting is effective.
With strongly elevated bilirubin due to pronounced hemolysis of erythrocytes, infusion therapy with the introduction of glucose, albumin, as well as plasmapheresis is indicated. In jaundice of newborns, phototherapy is very effective, in which ultraviolet irradiation of the skin contributes to the transformation of free toxic bilirubin into bound, easily excreted from the body.
Symptoms of increasing bilirubin
The severity of symptoms depends on the degree of increase in total bilirubin in the blood. The clinical picture with elevated bilirubin at the initial stage is characterized by the appearance of a jaundice tinge of the sclera of the eyes (jaundice). Subsequently, the symptom extends to the oral cavity, and at critical increases in the amount of pigment - the entire face, feet, palms and various parts of the body. Often the affected areas strongly itch.
It should be noted that this pattern is also characteristic of metabolic disorders of carotene and excessive consumption of vegetables (tomatoes, carrots). However, in this case, the whites of the eyes do not stain.
Often, elevated bilirubin causes pain and heaviness in the right hypochondrium, changes in the color of feces and urine.
A general practitioner, a gastroenterologist, a hematologist, an endocrinologist, or an infectious disease specialist can write out a referral for analysis. Indications for appointment:
- suspected pathology of the liver and bile ducts,
- the need for examination of infants with jaundice,
- jaundice in adults
- hereditary jaundice (syndrome) Gilbert,
- signs of hemolytic anemia,
- diagnosis of alcohol abuse patients
- the need for early detection of side effects of drugs with hepatotoxic or hemolytic properties,
- a history of chronic hepatitis
- liver pathologies (cirrhosis, liver failure, bile duct stones).
Total bilirubin increases - what does it mean in an adult how to treat?
In case the direct bilirubin is slightly increased (no more than 5 µmol / l), a repeated examination is prescribed after 3-5 days in order to exclude internal and external factors that affect the result. For example, the daily fluctuation of all laboratory parameters of blood or neglect of the subject of the rules of preparation for the collection of biomaterial.
Thus, blood bilirubin - 3 is considered an insignificant downward deviation, which can be caused by the recent use of alcohol, a large amount of coffee or drugs.
The treatment of any pathology is the task of the doctor. Self-diagnosis and self-selection of treatment methods can lead to a worsening of the condition of the disease, including death.
The reasons for which the total bilirubin is elevated are different and always are pathological in nature. Of particular importance in the differential diagnosis is what kind of fraction exceeds the norm.
What does it mean if an adult has elevated direct bilirubin?
The reasons for the increase in total bilirubin in the blood mainly due to the direct fraction include:
- holidocholithiasis - A pathological condition that occurs when gallstone disease. Manifested in the form of the formation of stones, blocking the lumen of the bile ducts. The importance of early detection is due to frequent complications. The lack of adequate treatment contributes to the development of cirrhosis, pancreatitis or pancreatonecrosis. The preferred treatment is endoscopic or liparoscopic stone removal. Relapse in 25% of cases within 5 years. Repeated surgery is accompanied by removal of the gallbladder,
- hepatitis C - an infectious disease that provokes inflammation of the liver. According to statistics, 150 million people are infected with the hepatitis C virus. They call it a “sweet killer” because the patient may not be aware of the infection for a long time. The patient can live up to 40 years without the manifestation of serious pathological signs. The prognosis depends on the presence of comorbidities. Thus, HIV-positive status significantly increases the risk of developing cirrhosis or liver cancer,
- primary sclerosing cholangitis - a rather rare pathology in which bile duct tissue becomes inflamed and expands. The end result is biliary cirrhosis accompanied by impaired immune regulation. At the same time, the immune system begins to destroy its own normal cells of the bile ducts, perceiving them as genetically alien material (antigens),
- malignant neoplasms in the pancreas,
- Dabin - Johnson syndrome - non-disruption of the process of release of the bound fraction from the liver cells, as a result of its abnormal movement in the opposite direction. In other words, bilirubin is not released from the liver, but on the contrary, it comes from the bile ducts into it. Pathology is genetic in nature and manifests as chronic jaundice. The prognosis of the disease is extremely favorable, since it does not affect the life expectancy,
- Rotor syndrome - similar to the previous disease, however, has a less pronounced degree of severity,
- alcoholic liver damage - disruption of the normal functioning of the liver cells due to prolonged (more than 10 years) alcohol intoxication and its decomposition products. Possible consequences: alcoholic hepatitis, cirrhosis, cancer and fatty infiltration of the liver.
Increase in total bilirubin due to indirect fraction
List of diseases accompanied by high levels of indirect bilirubin in the blood:
- autoimmune hemolytic anemia - occurs as a result of the production of autoimmune thermal antibodies (react at temperatures above 37 ° C). May be due to medication or leukemia,
- hemolytic anemia is characterized by increased destruction of red blood cells with excessive secretion of the indirect fraction in the blood,
- megaloblastic anemia - lack of vitamin B 12 leads to the deposition of immature red blood cells. This significantly increases the content of hemoglobin, and, as a consequence, its decomposition products,
- hereditary microspherocytosis - a change in the protein of the erythrocyte membrane, resulting in the violation of its integrity and enhancement of degradation processes
- Cooley's anemia is a mutation of the hemoglobin polypeptide chains. Bilirubin-enhancing genes - HBA1, HBA2 and HBB. Characterized by severe changes in the structure of the skull, nose and teeth. Chronic icterity, enlargement of the spleen and liver. Early manifestation of the disease leads to mental and physical underdevelopment,
- Gilbert's syndrome (non-hemolytic familial jaundice) is a pigmented benign liver disease in which the intracellular transport of unbound fraction to the site of attachment of sugar-containing substances is disrupted. Despite the chronic course throughout life does not affect its duration,
- Congenital Crigler-Nayar syndrome is a malignant disease accompanied by chronic jaundice and pathologies of the nervous system. Jaundice results from the malfunction of the transformation of indirect bilirubin to direct due to the lack / lack of necessary enzymes,
- malaria is an infectious disease, in the life cycle of the pathogen of which there is a reproduction phase in erythrocytosis. After maturation, parasitic plasmodium is released from red blood cells, triggering an active process of their destruction. One of the complications is the occurrence of chronic renal or hepatic failure.
What does it mean if the fractions are raised equally?
The reasons for the increase in total bilirubin in the blood, while the direct and indirect fraction is increased in equal shares, are considered:
- hepatitis viral or toxic (alcohol or drugs) nature,
- cirrhosis of the liver,
- infection with the herpes virus type 4, which is characterized by an increase in body temperature, damage to the liver and spleen, as well as changes in the cellular composition of the blood,
- damage to the liver tapeworm (echinococcosis). Once in the liver, the larvae begin to form echinococcal cysts in the form of bubbles, reaching sizes up to 20 cm. Slow growth of cysts makes it difficult to detect the infection earlier, and if they break, the larvae spread throughout the body,
- liver abscess - the formation of a cavity with pus in the body, is a consequence of appendicitis, gallstones or sepsis. In 90% of cases, with a competent approach to treatment, full recovery is achieved.
- there is no direct relationship between the severity of the pathology and the increase in bilirubin,
- An increase in any of the bilirubin fractions is always a sign of pathology and requires an immediate diagnosis clarification. The patient is scheduled for a comprehensive examination using ultrasound methods and additional tests,
- It is important to properly prepare for the delivery of the biomaterial, since many factors distort the accuracy of the results obtained. So, for 1 day before the study should not be the introduction of an intravenous contrast agent. Note that UV and fatty foods reduce the concentration of bilirubin in the blood. And physical or emotional overloads, as well as nicotine, lead to an increase. After at least 3 days, you should stop using any medications, as many of them have a direct effect on bilirubin metabolism.
Julia Martynovich (Peshkova)
In 2014 she graduated with honors from the FSBEI HE Orenburg State University with a degree in microbiology. Graduate postgraduate FGBOU Orenburg GAU.
In 2015 at the Institute of Cellular and Intracellular Symbiosis, the Ural Branch of the Russian Academy of Sciences underwent advanced training in the additional professional program "Bacteriology".
Winner of the All-Russian competition for the best scientific work in the nomination "Biological sciences" 2017.