Bilirubin (Total)

July 21, 2020

What is Bilirubin?

Bilirubin is a waste product from the normal breakdown of red blood cells. It has an orange-yellow pigment and comes from the breakdown of haem, a component of the protein haemoglobin. Haemoglobin gives red blood cells their characteristic red colour and transports oxygen around the body.[1]

Why take a Bilirubin blood test?

The concentration of bilirubin in the blood is used to identify liver disease. Bilirubin is excreted in bile and urine and increased levels are a good indicator for certain diseases.

Bilirubin is the substance which causes the yellow pigmentation in bruises and the yellow colour of jaundice. There are two types of measurement for bilirubin increased total or unconjugated and conjugated bilirubin. Increased unconjugated bilirubin can be caused by certain anaemias or a transfusion reaction. Whereas an elevated conjugated bilirubin level can be a result of a blockage in the liver or bile ducts, liver infections such as hepatitis, cirrhosis, drug reaction, long-term alcohol abuse or trauma.

You can test your bilirubin level by purchasing a simple at-home finger prick test kit which is then analysed at an accredited lab. Forth offers a Baseline Plus blood test which checks the level of 20 different biomarkers integral for good health, including bilirubin.

What function does Bilirubin have in the body?

Normal blood levels of bilirubin range from 0.2 to 1.2 mg/dL, so it is normal for some individuals to experience raised serum levels.[2] Contained in red blood cells is a protein called haemoglobin which is responsible for transporting oxygen around the body. The average lifespan for red blood cells is 120 days, after which they are removed from circulation by special immune cells called macrophages in the liver and spleen. Haemoglobin is made up of two components called haem and globin. Haem contains iron which can be removed and conserved to make new molecules of iron. When haem is broken down it is converted into bilirubin. Another protein, albumin attaches to the bilirubin, transporting it to the liver where it is secreted in bile, giving faeces their distinct colour.[3]

How do changes in Bilirubin affect health and wellbeing?

A build-up of unconjugated bilirubin (indirect) in the body causes jaundice, a yellowing of the skin and whites of the eyes. Jaundice can have several consequences for health and well-being, most notably the visible change in skin pigmentation. A change in skin colour can affect overall self-esteem and can damage your confidence. Some of the underlying causes of increased bilirubin levels have some painful side effects. For example, gallstones can obstruct the bile ducts resulting in jaundice and blockages cause severe abdominal pain.[4]

If you are worried about your liver health or just want to check what your levels of bilirubin are, you can test your key liver markers with a simple at-home blood test.

What can cause Bilirubin to change?

Bilirubin can change because of damage to the liver and so a liver function test may be required to determine the type of disease affecting the liver. There are several mechanisms by which the liver can become damaged, including:

  • Infection e.g. hepatitis
  • Increased/excess alcohol consumption
  • Poor diet e.g. non-alcoholic fatty liver
  • Trauma
  • Inherited factors such as haemochromatosis
  • Immune system issues e.g. primary biliary cirrhosis[5]

Increases in total bilirubin can be caused by:

  • Haemolytic anaemia
  • Sickle cell anaemia
  • Pernicious anaemia
  • Transfusion reactions

Extremely high levels of bilirubin have been shown to increase the risk of symptomatic gallstones. Bilirubin also has a role in the formation of gallstones within the gallbladder, one of the most common gastrointestinal tract diseases.[6]

Bilirubin levels are slightly increased by an inherited condition called Gilbert’s syndrome. A faulty gene causes the liver to have difficulty removing the bilirubin from the blood and causes symptoms such as stomach pain, irritable bowel syndrome (IBS), nausea, dizziness and fatigue. [7]


What are the most common symptoms?

Most common symptoms of gallstones are:

  • Abdominal pain
  • Fever
  • Itchy skin
  • Jaundice
  • Increased heart rate
  • Diarrhoea
  • Confusion
  • Loss of appetite
  • Chills

The most common symptoms of liver damage are:

  • Feeling tired and weak all or most of the time
  • Reduced appetite
  • Loss of libido
  • Jaundice (yellowing of the skin and whites of the eyes
  • Itchy skin
  • Nausea and/or vomiting[8]

How to keep Bilirubin in the healthy range

Diet and lifestyle are major influences on the health of the liver. It is essential to eat a healthy, balanced diet to ensure the liver remains healthy.  Make sure you are eating a good amount of dietary fibre as this will help to keep your digestive tract healthy, particularly because the liver filters the blood from the digestive tract. Good sources of fibre are fruit, vegetables and whole grains. Eating lots of simple carbohydrates like white bread, cakes and pastries can increase blood glucose levels rapidly and lead to weight gain, so you need to be aware of how much you are eating. Swapping simple carbohydrates for wholegrains will slow down the rise in blood sugar and they are healthier for the liver, plus they are high in fibre.[9] Obesity is a risk factor for diseases such as type II diabetes and non-alcoholic fatty liver disease.

Alcohol can increase the levels of bilirubin in the blood, particularly if it is consumed in excess. Alcohol damages the liver and prevents it from carrying out its normal functions effectively. [10] Therefore, alcohol intake should be kept as low as possible and within the guidelines of not exceeding 14 units of alcohol per week. You should also aim to have alcohol free days and spread the units across the week rather than binging in one go. Because alcohol dehydrates the body, staying hydrated is important. The liver is approximately 73% water and requires water to function. You should aim to drink approximately 2 litres of water per day, even if you’re not drinking any alcohol.

If increased levels of bilirubin are the result of Gilbert’s syndrome, research has shown that the Palaeolithic Ketogenic Diet may help to reverse the associated symptoms. However, you should consult your GP before changing your diet, particularly as the diet is high in animal fat, meat and eggs.


[1] Lab Tests Online. (2016). Bilirubin. Available at:

[2] Fujiwara, R et al. (2018). Systemic Regulation of Bilirubin Homeostasis: Potential Benefits of Hyperbilirubinemia. Hepatology: 67(4), pp 1609-1619.

[3] Dean L. (2005). Chapter 1, Blood and the cells it contains. In: Bethesda (MD) ed: Blood Groups and Red Cell Antigens. National Center for Biotechnology Information (US); Available from:

[4] NHS. (2018). Gallstones. Available at:

[5] National Health Service. (2017). Liver Disease. Available at:

[6] Stender, S et al. (2013). Extreme Bilirubin Levels as a Causal Risk Factor for Symptomatic Gallstone Disease. JAMA Intern ed: 173(13), pp 1222-1228.

[7] National Health Service. (2015). Gilbert’s Syndrome. Available at:

[8] National Health Service. (2017).  Liver Disease. Available at:

[9] (2019). Carbohydrate and Diabetes. Available at:

[10] Mathurin, P., Abdelnour, M., Ramond, M, J et al., (2003). Early Change in Bilirubin Levels Is an Important Prognostic Factor in Severe Alcoholic Hepatitis Treated with Prednisolone. Hepatology: 38(6), pp 1363-1369.

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This information has been medically reviewed by Dr Nicky Keay

Nicola has extensive clinical and research experience in the fields of endocrinology and sport and exercise medicine. Nicky is a member of the Royal College of Physicians, Honorary Fellow in the Department of Sport and Exercise Sciences at Durham University and former Research Fellow at St. Thomas' Hospital.

Dr Nicky Keay

Dr Nicky Keay

BA, MA (Cantab), MB, BChir, MRCP.