Bilirubin High: Direct vs Indirect, Gilbert Syndrome, and When to Image

Elevated bilirubin causes yellowing of the eyes/skin and dark urine. Google queries often include "bilirubin 2.0", "high indirect bilirubin", "Gilbert syndrome", "direct bilirubin high". The split into indirect (unconjugated) and direct (conjugated) narrows causes.

Indirect (unconjugated) bilirubin high

• Gilbert syndrome: benign, intermittent rises during fasting, illness, stress. LFTs otherwise normal.
• Hemolysis or ineffective erythropoiesis: check reticulocytes, LDH, haptoglobin, smear.
• Medications (rare) decreasing conjugation or transport.

Direct (conjugated) bilirubin high

• Cholestasis/obstruction: stones, strictures, tumors; ALP and GGT often high.
• Hepatocellular injury: viral hepatitis, drug-induced, autoimmune; ALT/AST higher.
• Inherited cholestatic disorders (rare).

Educational next steps

1. Fractionate bilirubin; review meds, alcohol, fasting, and illness.
2. If direct fraction is high or cholestatic pattern present, clinicians commonly order an ultrasoundand may add MRCP depending on findings.
3. If isolated indirect elevation with normal labs and classic history, Gilbert syndrome is likely and benign.

When to seek urgent care

• Jaundice with fever, severe abdominal pain, confusion, or bleeding.
• New jaundice in pregnancy or after starting a new drug.

Educational use only. Not a diagnosis or treatment plan.