Home Forums Discussions General Discussion Gilberts syndrome?

To all you gastros, internists, and generally smart guys/gals-

When do you work up isolated elevated bilirubin?

Lets say bili 3.1, incidental finding, all other LFTs normal, no evidence of hemolysis, no family hx of liver disease, totally asymptomatic.

Ignore and call it Gilberts, or evaluate further?

Now lets say bili 5 years ago was normal. Any change in thoughts?

Thanks. Gene

If less than 2, and the only LFT elevated, I just follow it. If 2 or over, I usually check a direct or conjugated bilirubin level.

Gilbert's (up to 5% of "normal" people) should have a higher unconjugated bilirubin. The other major reason for unconjugated bilirubinemia is hemolysis (sickle cell, hereditary hemolytic syndromes like G-6-PD, some drugs or contrast agents). There should be some other evidence of hemolytic syndromes though, such as the blood smear, low haptoglobin or high LDH.

If conjugated (direct) bilirubin is elevated more than unconjugated (indirect) bilirubin, there typically is a problem associated with either:
-- decreased hepatic clearance of bilirubin, i.e., viral hepatitis, drug reactions (especially antipsychotics & chemo drugs), alcoholic liver disease; or
-- biliary obstruction, i.e., bile duct stone or stenosis, tumors

Although I have never seen these, the textbooks always mention Rotor, Dubin-Johnson & Crigler-Najjar syndromes as a cause of increased levels of bilirubin.

I have Gilberts, but I am not included in the statistics, because I am anything but normal.

I did fail to mention Bert Syndrome.

I hear 2, do I have a 2.5?

Seriously, John, thanks for the reply. In 25 years of practice, I cannot recall one time that an isolated elevated bili indicated a problem.

Any other thoughts on this?

If this board gets really slow, then I will start a thread about isolated elevated alk phos....

Gene

Gene,
I agree with what John has said.
I think your patient with a bili of 3.1 will indeed have Gilbert's; I suppose your question is about the extent of work-up needed. I would fractionate the bilirubin (if not automatically done by the lab) to be sure it is primarily unconjugated. Assuming that it is, and given the other negatives you describe, I would assume it is Gilbert's. The only thing I would do is repeat the bilirubin at some later point. The bilirubin tends to fluctuate fairly widely in patients with Gilbert's, often due to a relatively mild viral illness or dehydration. Supposedly even stress will do it. A follow-up bilirubin that drops into the two's would be reassuring.

Thanks John and Jon,

Actually, the most useful piece of info is about the fluctuation in bili with Gilberts, I had thought that it was relatively constant.

I usually order a CMP, which gives only total bili.

I will probably order fractionated bilis for a while, and when they all come back as expected, fall back into my evil ways of ignoring them....

Gene

I admit, I don't lose too much sleep at night over all those Crigler-Najjar syndromes I am missing. And seeing all adults, most of them over 65, as soon as I open my mouth about the high bili, they cut me off with a quick "my doctors told me it is Gilbert's syndrome".