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Suggested protocol for investigation of a slightly raised isolated bilirubin in an asymptomatic adult patient in primary care

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Recommended investigation for isolated raised bilirubin in primary care (1):

  • values <1.5 times upper limit of normal (ULN)
    • suggested that should retest LFTs in 1-3 months unless clinical suspicion of disease
      • if clinical suspicion of disease then check the proportion of unconjugated and conjugated bilirubin; if concern about possible haemolysis then test haptoglobin, LDH and blood count with reticulocyte count

  • values >1.5 ULN:
    • it is suggested that confirm proportion of indirect (unconjugated) bilirubin versus conjugated bilirubin; test haptoglobin, LDH and blood count with reticulocyte count
      • Gilbert's syndrome is probable if >70%, unconjugated (and no evidnce of haemolysis): no further testing needed if non-progessive on interval retesting (1)
      • if haemolysis (unconjugated bilirubin > 70%) is suspected then haematology referral (2)
      • if conjugated bilirubin > 50% then consider rare causes such as Dubin-Johnson syndrome and drug induced (2)

  • values > 3 x ULN:
    • it is probable that raised bilirubin is a result of disease process
      • referral and further investigation required
        • consider ultrasound (conjugated >50%) or haemolysis (unconjugated >70%)

Notes:

  • values up to 20% over ULN are likely to be statistical rather than clinical 'abnormals'
  • referral to secondary care is indicated if bilirubin is raised > 2 ULN (unexplained by laboratory tests) (1)

Reference:

  1. Clinical Knowledge Summaries (accessed 6/4/07). How should I investigate an isolated 'slightly raised' bilirubin in an asymptomatic adult? www.cks.library.nhs.uk
  2. City and Hackney CCG. Abnormal Liver Function Tests (LFTs) in Adults (Accessed 1/9/19)

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