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Hyperbilirubinaemia - DRAFT

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Overview

A raised bilirubin level is a common finding on LBT testing.

If associated with other abnormal liver enzymes then please investigate according to the Liver disease pathways.

If it is an isolated finding then please consider the advice on the page below.

Initial investigation in primary care

An isolated raised bilirubin level in patients who are otherwise well usually has a benign cause (most likely Gilbert's syndrome). However, the following blood tests should be considered if a previous diagnosis of Gilbert's has not been made:

Repeat LBTs after 2-4 weeks
Bilirubin (total and conjugated)
FBC
Reticulocytes (or 'retic count' in UHBW ICE)
Haptoglobin
LDH

Unconjugated Hyperbilirubinaemia

If the majority (>50%) of the elevated bilirubin comprises the unconjugated fraction then the cause, in the absence of haemolysis, is virtually always Gilbert’s syndrome. As Gilbert’s syndrome is not associated with liver disease or ill health, any such individuals should be fully reassured (1).

There is advice for patients available below:

Gilbert's syndrome - NHS

If haemolysis is suspected, then consider requesting Haematology Advice and Guidance via eRS initially.

Crigler-Najjar syndrome is a rare autosomal recessive disorder of bilirubin conjugation characterised by severe unconjugated hyperbilirubinemia. It should be considered if total bilirubin is >60umol/l. Consider urgent hepatology advice or referral via eRS.

Conjugated Hyperbilirubinaemia

If the unconjugated fraction is <50% then conjugated hyperbilirubinaemia should be considered and is typically due to parenchymal liver disease or obstruction of the biliary system (1).

A full history and examination should be performed:

Red flags such as persistent jaundice, weight loss or anorexia should prompt a USC CT scan/USS or USC/2WW referral - see Upper GI - USC (2WW)
Alcohol history
Drug history - looking for hepatoxic drugs
Travel - hepatitis risk
Hepatospenomegaly
Signs of chronic liver disease (spider naevi, palmar erythema, ascites)
Lymphadenopathy (suggests malignancy or infection)

Further investigations should be considered if not already done:

Non-invasive liver screen bloods (NILS) - use ICE profile.
USS liver

If there is still diagnostic uncertainty then consider requesting Hepatology Advice and Guidance via eRS.

Referral

If necessary, a referral should be considered according to suspected underlying cause or after seeking advice and guidance.

Resources

(1) Guidelines on the management of abnormal liver blood tests.pdf (BSG guidance 2017)

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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