The cause for hyperbilirubinemia in a patient may not be immediately obvious. A battery of simple tests can often identify the probable pathologic process.

Processes that can explain hyperbilirubinemia:

(1) hemolysis

(2) hepatocellular disease

(3) biliary obstruction


Screening tests:

(1) urobilinogen

(2) urine conjugated bilirubin

(3) urine hemoglobin

(4) fecal color

(5) indirect bilirubin level

(6) ratio of direct to total bilirubin

(7) serum alkaline phosphatase

(8) serum ALT


Test Hemolysis Hepatocellular Obstructive
urobilinogen usually increased, may be normal negative to increased negative
urine conjugated bilirubin normal increased increased
urine hemoglobin positive negative negative
fecal color dark brown normal to pale pale to white
indirect bilirubin level increased variable normal
ratio of direct to total bilirubin < 20% 20 - 60% > 50%
serum alkaline phosphatase normal normal to 2 times ULN > 2 times ULN
serum ALT normal > 2 times ULN normal to 2 times ULN



• This assumes that only 1 process is occurring and no confounding processes are present.

• These findings assume moderate to severe disease. However, mild disease might not cause hyperbilirubinemia.

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