Total Bilirubin (TBIL)

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Bilirubin is an orange-yellow pigment, a waste product primarily produced by the normal breakdown of haem, which is a component of a protein called haemoglobin. Haemoglobin is found in red blood cells and gives them their characteristic red colour and is used to carry oxygen around the body. Bilirubin is ultimately processed by the liver to allow its elimination from the body. This test measures the amount of bilirubin in the blood to evaluate a person's liver function or to help diagnose anaemia caused by excessive red blood cell destruction. The normal life-span of red blood cells in the circulation is 120 days. When they are broken down the haem is initially released from the haemoglobin and then converted to unconjugated bilirubin. The unconjugated bilirubin is not water-soluble so it is carried by proteins in the blood to the liver. Within the liver, the unconjugated bilirubin has sugars attached to form water-soluble conjugated bilirubin. This is secreted into bile and carried to the intestine where bacteria break it down, eventually producing the brown pigment that colours normal stools. A small amount (approximately 250 to 350 milligrams) of bilirubin is produced daily in a normal, healthy adult. Normally, small amounts of unconjugated bilirubin are found in the blood, but virtually no conjugated bilirubin is present. Both forms can be measured by the laboratory tests but total bilirubin result (a sum of these) is usually reported.


Bilirubin is one of the most commonly used tests to assess liver function. Approximately 85% of the total bilirubin produced is derived from the heme moiety of haemoglobin, while the remaining 15% is produced from RBC precursors destroyed in the bone marrow and from the catabolism of other heme-containing proteins. After production in peripheral tissues, bilirubin is rapidly taken up by hepatocytes where it is conjugated with glucuronic acid to produce bilirubin mono- and diglucuronide, which are then excreted in the bile.

A number of inherited and acquired diseases affect 1 or more of the steps involved in the production, uptake, storage, metabolism, and excretion of bilirubin. Bilirubinemia is frequently a direct result of these disturbances.

The most commonly occurring form of unconjugated hyperbilirubinemia is that seen in newborns and referred to as physiological jaundice.

The increased production of bilirubin, that accompanies the premature breakdown of erythrocytes and ineffective erythropoiesis, results in hyperbilirubinemia in the absence of any liver abnormality.

The rare genetic disorders, Crigler-Najjar syndromes type I and type II, are caused by a low or absent activity of bilirubin UDP-glucuronyl-transferase. In type I, the enzyme activity is totally absent, the excretion rate of bilirubin is greatly reduced and the serum concentration of unconjugated bilirubin is greatly increased. Patients with this disease may die in infancy owing to the development of kernicterus.

In hepatobiliary diseases of various causes, bilirubin uptake, storage, and excretion are impaired to varying degrees. Thus, both conjugated and unconjugated bilirubin are retained and a wide range of abnormal serum concentrations of each form of bilirubin may be observed. Both conjugated and unconjugated bilirubins are increased in hepatitis and space-occupying lesions of the liver; and obstructive lesions such as carcinoma of the head of the pancreas, common bile duct, or ampulla of Vater.


No test preparation is necessary. The blood sample should ideally be protected from bright light before analysis.


A doctor usually requests a bilirubin test in conjunction with other laboratory tests including ALP, AST and ALT as a group called liver function tests (LFTs) when a patient has a history, signs or symptoms suggesting abnormal liver function. LFTs may be requested when a patient:
  • shows evidence of jaundice
  • has a history of drinking excessive amounts of alcohol
  • has suspected drug toxicity
  • has been exposed to hepatitis viruses
Other signs and symptoms that may be present include:
  • dark, amber-coloured urine
  • pale stools
  • itching
  • nausea and vomiting
  • abdominal pain and/or swelling
  • fatigue and general malaise


Adults and children: Bilirubin concentrations can be used to identify liver disease or to monitor the progression of jaundice. Increased total or unconjugated bilirubin may be a result of haemolytic, sickle cell or pernicious anaemias or a transfusion reaction. If conjugated bilirubin is elevated, there may be some kind of blockage of the liver or bile ducts, hepatitis, trauma to the liver, cirrhosis, a drug reaction, or long-term alcohol abuse.

An excessive unconjugated bilirubin concentration may result from the breakdown of red blood cells due to blood typing incompatibility between the mother and her infant. For example, if the mother is Rhesus negative and the foetus inherits the father’s Rhesus positive trait, foetal red blood cells may cross the placenta into the mother’s blood and she may develop antibodies which cross back into the foetus and cause haemolysis of the foetal Rh-positive red blood cells, resulting in excessively elevated unconjugated bilirubin.

Determining conjugated and unconjugated bilirubin concentrations in new-borns with jaundice is standard medical care. Malformation of the bile ducts (biliary atresia) obstructs the flow of bile, damaging the liver and causing raised concentrations of conjugated bilirubin. The condition requires early surgical treatment to avoid the need for liver transplantation.


The laboratory test results are NOT to be interpreted as results of a "stand-alone" test. The test results have to be interpreted after correlating with suitable clinical findings and additional supplemental tests/information. Your healthcare providers will explain the meaning of your tests results, based on the overall clinical scenario. Certain medications that you may be currently taking may influence the outcome of the test. Hence, it is important to inform your healthcare provider of the complete list of medications (including any herbal supplements) you are currently taking. This will help the healthcare provider interpret your test results more accurately and avoid unnecessary chances of a misdiagnosis.

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