conjugated bilirubin Direct bilirubin Bilirubin chemically bound to a glucuronide in the liver, which is excreted in bile by the liver and stored in the gallbladder or transferred to the duodenum Ref range Direct BR: 0–0.3 mg/dL ↑ in Bile duct obstruction, cirrhosis, Crigler-Najjar … Urine -dark in colour, usually brown with yellow foam. Indirect. Conjugated bilirubin measurement was judged to be more responsive to developing or resolving cholestasis then direct bilirubin. Biliary obstruction commonly refers to blockage of the bile duct system leading to impaired bile flow from the liver into the intestinal tract. 1972. … It is a result of hemoglobin breakdown. This type of bilirubin is called unconjugated, or indirect, bilirubin. The infants with positive screening results in stage 1 were more likely to have been tested with direct vs conjugated bilirubin, reflecting the inherent limitations of the direct bilirubin assay that also measures small amounts of unconjugated bilirubin. Albumin usually has a clear to pale yellow colour but may occasionally have a green discolouration, which is attributed to small amounts of the degradation products of bilirubin, biliverdin and lumirubin (1). Describe the metabolism of bilirubin. •Clarify which liver problems affect which LFTs. Infants with severe jaundice and pale stools should undergo fractional bilirubin measurements of conjugated and unconjugated bilirubin. Direct Bilirubin, Indirect Bilirubin (calculated), Total Bilirubin. Measurement of serum conjugated bilirubin (CB) or direct bilirubin (DB) is recommended to rule out cholestasis. [1] 1,2, dr. mark deneau. Gemtuzumab ozogamicin (GO) is the first antibody-drug conjugate (ADC) approved for induction therapy of AML. How to use unconjugated in a sentence. bilirubin Serum bilirubin is a mixture of α, β, γ and δ fragments which are unconjugated, singly conjugated, doubly conjugated and covalently bound to albumin, respectively. The indirect (unconjugated) bilirubin is the bad kind that hangs around in the body and ends up causing all the problems. When cholestasis is relieved, serum bilirubin values fall slowly to normal; this is caused in part by the formation of bilialbumin in which bilirubin and albumin (half-life, 3 weeks) are bound covalently. This is called conjugated bilirubin or direct bilirubin. While physiologic jaundice appears after 3 to 4 days and subsidies itself. In the liver, bilirubin is conjugated with glucuronic acid by the enzyme glucuronyltransferase, first to bilirubin glucuronide and then to bilirubin diglucuronide, making it soluble in water: the conjugated version is the main form of bilirubin present in the "direct" bilirubin fraction. The mean conjugated bilirubin concentration, calculated from diazo determina- tion of total bilirubin plus fractionation by alkaline methanolysis followed by thin-layer chromatography, was comparable in Gilbert's syndrome fasting overnight and healthy subjects (1.2 0.5 vs… It is a byproduct that occurs after the breakdown of hemoglobin. Conjugated bilirubin depicts that sugar has been attached to it. This form of bilirubin is water-soluble and goes into the bile. A small amount of conjugated bilirubin takes an alternate route and is secreted back across the sinusoidal pole of the hepatocyte into plasma via an MRP3 transporter. This is seen in the newborn, where the liver is immature and lacks sufficient conjugating enzymes. If the conjugated bilirubin levels are higher than the unconjugated bilirubin, this is typically due to a malfunction of the liver cells in conjugating the bilirubin. In Gilbert's syndrome, unconjugated bilirubin ranged between 90 and 99%, in healthy subjects between 72 and 90%, in patients with chronic persistant hepatitis between 68 and 85% and in patients with chronic hemolysis between 81 and 89% of total. This is most useful when all the standard liver test results are normal, except the total bilirubin. †Editorial Board After completing this article, readers should be able to: 1. Bilirubin that has gone to the liver and undergone further metabolic process is called conjugated bilirubin. bilirubin Serum bilirubin is a mixture of α, β, γ and δ fragments which are unconjugated, singly conjugated, doubly conjugated and covalently bound to albumin, respectively. Measurement of bilirubin fractions (conjugated vs unconjugated) in serum is not usually required in infants who present as described above. Within 1 day. Tests: elevated bilirubin. Urine bilirubin: Conjugated bilirubin excreted into GIT is reabsorbed in very small amounts. Once in plasma, the conjugated bilirubin can be secreted into urine or can undergo reuptake into the hepatocyte by the organic anion transporting polypeptides (OATP1B1 and OATP1B3). Kidneys filter soluble form and it appears in urine. While in conjugated hyperbilirubinemia, conjugated bilirubin level is high and more than 20% of the total bilirubin. Overall Bottom Line Jaundice occurs when there is an elevation in the plasma total bilirubin level that is visible clinically. 90,000 U.S. doctors in 147 specialties are here to answer your questions or offer you advice, prescriptions, and more. Bilirubin testing: Testing for fractionated bilirubin includes testing for total bilirubin, direct bilirubin, and indirect bilirubin (calculated). Direct bilirubin is the more soluble, less toxic and is the conjugated form of bilirubin. Conjugated bilirubin should be measured in any baby who remains jaundiced after two weeks of life (3 weeks for preterm infants). Bilirubin is measured in milligrams per deciliter (mg/dL). In the adult patient, the main… The nomogram is based on TOTAL bilirubin (not fractionated bilirubin). In patients, when the serum total bilirubin levels exceed 3.0 mg/dL, jaundice becomes clinically apparent. Garcia et al Hospitalization period was longer in the case group (8 Vs … This is the American ICD-10-CM version of E80.7 - other … To measure fractionated bilirubin, 11 of the 12 participating hospitals used the Ektachem system and reported conjugated bilirubin measurements; the remaining hospital used the diazo method and reported direct bilirubin measurements. defined is if the absolute value of conjugated bilirubin is > 17umol/L in the context of a total serum bilirubin <85 umol/L. Click here for a list of all centers ; Clinical Departments . Indirect bilirubin is the difference between total and direct bilirubin. Serum conjugated bilirubin is > 20% of total bilirubin (if total bilirubin is > 5mg/dL). The spleen sends the pigment to the liver, where it is conjugated with albumin to make it water soluble. The mechanism responsible for transporting unconjugated bilirubin into the hepatocyte has not been identified. The present study investigates the nephroprotective and the molecular mechanisms effects of Liza aurata protein hydrolysates (LAPHs) against paracetamol induced nephrotoxicity and oxidative stress in rats. Direct hyperbilirubinemia is also considered pathologic, (i.e., direct bilirubin >1.5-2 mg% or > 20% of the total bilirubin) (8). Evaluate a child of any age who has conjugated hyperbilirubinemia. Use. High bilirubin levels are usually a sign that something’s not quite right in your liver or gallbladder. Hence, a central feature of conjugated (or direct) hyperbilirubinemia is a practical clinical marker and surrogate of cholestasis. The conjugated bilirubin … Determine the fractionated bilirubin levels. The red blood cells in the body are constantly building and breaking down and as a result many by products are released as waste. Bilirubin fractions in theory seem valuable for classifying the possible etiologies of hyperbilirubinemia. Some of these conditions aren’t too serious, but it’s important to monitor and treat them. M. C. Hughes Unconjugated bilirubin is a waste product that results from the process of breaking down old red blood cells. Other signs and symptoms that suggest Gilbert's syndrome as well as a number of other liver conditions include dark urine and abdominal pain. When used in fractionated doses, GO combined with the conventional cytarabine/anthracycline-based induction chemotherapy significantly improves the outcome of … Urine bilirubin: Conjugated bilirubin excreted into GIT is reabsorbed in very small amounts. The distinction between conjugated and unconjugated bilirubin is not essential at this stage but, if jaundice persists for more than two weeks, it might be reasonable to measure bilirubin fractions. Turnaround time is defined as the usual number of days from the date of pickup of a specimen for testing to when the result is released to the ordering provider. Sometimes called free bilirubin or indirect bilirubin, it is a waste product that results from the process used to break down old red blood cells. The 2021 edition of ICD-10-CM E80.7 became effective on October 1, 2020. post-hepatic. Bile is a substance that contains bile salts, bilirubin, and cholesterol and is continuously synthesized in the liver hepatocytes. *Note: The default unit of measure for total bilirubin is mg/dl.Please select µmol/L if your bilirubin values are captured in the global standard SI metric units. If there is an elevation of conjugated bilirubin at 14 days of age or earlier, it is by definition neonatal cholestasis. Although δ bilirubin measurement is available, it has not gained wider utility. fractionated bilirubin in >250,000 utah newborns confirms conjugated or direct bilirubin is elevated in the newborn period in biliary atresia: implications for newborn screening. Recognize the signs and symptoms of Wilson disease. Direct bilirubin 0, 0.1, 0.2, and 0.3 is normal results and cannot be a cause of jaundice unless indirect bilirubin continue to be high. 1. ›. Indirect bilirubin is the unconjugated form of bilirubin. On the other hand, the proportion of PHCU nurses who said “beyond 14 days” was significantly higher than of hospital nurses (24.4 vs 6.4%; p < 0.05). B. Carcinoma of the head of pancreas – this could also cause biliary obstruction, similar to A. Blood type and direct Coomb’s test 4. Note that in a very young baby, conjugated bilirubin levels can be falsely normal ; These levels show if bilirubin is bound with other substances by your child's liver. Specimen Serum (1 mL) collected in gold-, red-, or red/gray-top tube. Uses of Bilirubin, Fractionated Test. ! The red blood cells in the body are constantly building and breaking down and as a result many by products are released as waste. Blog.healthians.com DA: 19 PA: 50 MOZ Rank: 76. Bilirubin testing: Testing for fractionated bilirubin includes testing for total bilirubin, direct bilirubin, and indirect bilirubin (calculated). If persistent jaundice at 2-4 wo, do a fractionated bili Time is of the essence in biliary atresia While biliary atresia and other surgical causes are important to R/O, keep an open mind in workup of neonatal conjugated hyperbili In an older child, history looking at risk factors is critical to orient diagnosis An analysis of fractionated bilirubin should be carried out in all instances of hyperbilirubinemia to determine the proportions of unconjugated/indirect and conjugated/ direct bilirubin. Indirect bilirubin is not soluble in water, although it is soluble in fats. Testdirectory.questdiagnostics.com DA: 34 PA: 45 MOZ Rank: 98. Bilirubin is released from the destroyed red blood cells and passed on to the liver. Direct (conjugated bilirubin level) If >15% may go on to conjugated screen with LFTs, coagulation, viral serology, alpha 1 antitrypsin deficiency, hepatic US, etc) 3. Bilirubin, Fractionated - Measurement of the levels of bilirubin is used in the diagnosis and treatment of liver, hemolytic, hematologic, and metabolic disorders, including hepatitis and … Common use A multipurpose lab test that acts as an indicator for various diseases of the liver or for disease that affects the liver. Total bilirubin elevation can occur in either cholestatic or hepatocellular diseases. 1,2 The degradation of haem by mammals and its excretion as conjugated bilirubin. Indirect bilirubin is calculated by subtracting direct bilirubin from the total: indirect serum bilirubin = total serum bilirubin − direct serum bilirubin. Ordinarily bilirubin levels in these patients do not exceed 4 mg/dL from hemolysis alone and the conjugated fraction is less than 10% (Johnson et al, 1985, West et al, 1992). Then, differences among the measurement principles were examined (year; 2017). Fortunately, there are elaborate physiologic mechanisms for its detoxification and disposition. high conjugated bilirubin means what type of hepatic jaundice? This is commonly seen with drug reactions, hepatitis, as well as any type of liver disease. The indirect bilirubin is … Direct (conjugated) hyperbilirubinemia cases are relatively uncommon. Bilirubin Fractionation Lab Test Includes Total, Direct And Indirect Bilirubin CPT Code(s) 82247, 82248. Specializes in Pathology. Guidelines on the management of abnormal liver blood tests. Anesthesiology ; Emergency Medicine ; Family and Community Medicine The subsequent laboratory investigation for the patient discussed here included an order for a CMP, not an order for a BMP plus LFTs, which would have given the breakdown of conjugated versus unconjugated bilirubin (fractionated bilirubin). Some bilirubin is bound to a certain protein (albumin) in the blood. Separate serum or plasma from cells within 45 minutes of collection. However, conjugated bilirubin is water-soluble and therefore may be excreted from the body in the urine when concentrations increase in the blood. A bilirubin test measures the levels of bilirubin in your blood. Daniel W. Thomas, MD† 1. In the liver, bilirubin is changed into a form that your body can get rid of. It is very similar to phytochrome and phycobilin of certain plants and algae. Specializes in Pathology. – Fractionated bilirubin – AST, ALT, Alk phos – Liver function tests – CBC – Bacterial cultures . Conjugated vs Unconjugated Bilirubin Bilirubin is a compound containing four pyrrole rings connected to a larger porphyrin ring. Gilbert's syndrome is an inherited (usually autosomal recessive) metabolic disorder characterized by a mild and intermittent elevation of unconjugated (indirect) bilirubin levels, due to defective conjugating enzymes in the liver. The rate of photodegradation of unconjugated bilirubin (Bu) was nearly twice that of monoconjugated bilirubin (mBc) and three fold that of diconjugated bilirubin (dBc); delta bilirubin (Bd) was the most stable against photoirradiation1). E80.7 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. Bilirubin is not normally present in the urine. However, CB and DB levels are not the same: CB is a measure of bilirubin that has been conjugated with glucuronic acid in the liver. Within physiologic range, bilirubin has cytoprotective and beneficial metabolic effects, but in high levels it is potentially toxic. 3. INTRODUCTION. Purpose: Fractionated radioimmunotherapy may improve therapeutic outcome by decreasing heterogeneity of the dose delivered to the tumor and by decreasing hematologic toxicity, thereby allowing an increased amount of radionuclide to be administered. Direct bilirubin <15% suggests a problem in the “pre-conjugative” phase. Thus, it is hyperbilirubinemia in which conjugated bilirubin is <1 mg/dL (17 micromol/L) …. Urine -dark in colour, usually brown with yellow foam. The normal range of Bilirubin in the body is in between 0.3–1.0 mg/dL. cholangitis should be undertaken. Bilirubin is sensitive to light and oxygen. Am J Clin Pathol 1985;84:518–523. No. A.Fractionated Bilirubin B.Ceruoloplasmin C.GGT D.SPEP Goals •List the most common reasons for abnormal LFTs. An example of normal values for adults is: Total bilirubin: 0.3 to 1.9 mg/dL. Bilirubin comes from the breakdown of red blood cells and is excreted by the liver. We have studied this relationship in 13 bone marrow transplant recipients who had episodes of combined conjugated hyperbilirubinemia and renal impairment. Conjugated (direct) bilirubin is the kind of bilirubin you want to have if you have to have any because it's more likely to be excreted through the stools. Lathe GH. A bilirubin test measures total bilirubin. With poor uptake into the liver you can only state that there is cholestasis. When total bilirubin is abnormal, it is important to measure direct and indirect bilirubin levels. Includes. Conjugated (direct) hyperbilirubinemia (>1.0 mg/dL, 17 μmol/L) is considered pathological and warrants diagnostic evaluation (1A). Testing for fractionated bilirubin includes testing for total bilirubin, direct bilirubin, and indirect bilirubin. Unconjugated hyperbilirubinemia in the newborn: Pathogenesis and etiology. Conjugated (direct bilirubin) will be >2 mg/dL. An increase in the level of conjugated bilirubin means an indication towards hepatobiliary disease. 2. Mean indirect bilirubin values were significantly lower in the case group in comparison with control group (17.9 vs 21.2 mg/dl, P<0.001). Figure 1 Major pathways involved in bilirubin production, conjugation, and excretion. Direct bilirubin: 0.0 to 0.3 mg/dL. 2. Spectrophotometry (SP) Reference Range(s) This can also been seen due to some sort of blockage of the bile ducts. Bile acids may be measured to investigate obstructive cholestasis in pregnancy. The fractionated bilirubin breaks down the total bilirubin into direct and indirect bilirubin so that the clinician is better able to determine the cause for hyperbilirubinemia. Bilirubin is a yellow colored pigment that the liver produces when red blood cells are broken down and recycled. Bilirubin and Bilirubin Fractions Synonym/acronym: Conjugated/direct bilirubin, unconjugated/indirect bilirubin, delta bilirubin, TBil. Jaundice that persists beyond 2 weeks should be evaluated beginning with a fractionated bilirubin (5). • Bilirubin greater then 2.5 mg/dl! *Children’s Hospital of Los Angeles, Los Angeles, Calif 2. Direct bilirubin is also conjugated bilirubin and indirect is also called unconjugated bilirubin or free blilrubin. Total bilirubin is a combination of both direct (conjugated) and indirect (unconjugated) bilirubin. Essays Biochem. dr. stephen l guthery. If the unconjugated bilirubin levels are higher than the conjugated bilirubin, this could be caused by hemolytic or pernicious anemia, transfusion reactions, and cirrhosis. •Describe what the various LFTs actually measure. Jaundice occurs when the bilirubin level is above 2.5 mg/dl. The unconjugated bilirubin is substantially higher in patients with the UDP-glucuronyltransferase genetic defect of Gilbert's syndrome (Lin et al , Passion et al , 1999). Total bilirubin includes both the conjugated and unconjugated (free) forms and, if elevated, is usually indicative of liver damage or hemolysis. An asymptomatic man has had an elevated bilirubin level (1.5-2.4 mg/dL) for the past two years. In most cases a total bilirubin … Bilirubin inhibits the UPS. The bilirubin would already be conjugated, so this would be a conjugated bilirubinemia. In acute liver injury, the pattern of direct hyperbilirubinemia is similar to that in obstructive jaundice — typically 50% of total bilirubin. Bilirubin level thus serves as a measure of liver and bile tract function. Presence of bilirubin implies Conjugated hyperbilirubinemia. Bilirubin can be considered as an unravelled product of haem, but although it is usually represented in two dimensions on the printed page (Figures 1 and 2), its three-dimensional structure and hence the number of exposed reactive groups is an important factor in its further metabolism. Alkaline phosphatase (ALP) is one kind enzyme found in your body. Despite high levels of conjugated bilirubin in serum, rats with a common bile duct ligation and a neonate with biliary atresia excreted only traces of … Rula Harb, MD* 2. Serum total bilirubin – used for treatment decisions, not fractionated level 2. Kidneys filter soluble form and it appears in urine. Infants who remain jaundiced at 2 weeks of age should have their bilirubin fractionated. Unconjugated bilirubin is protein-bound. It does not represent any danger to you and some people can go as high as 5 or 6. Gilbert syndrome is a harmless genetic condition in which the liver does not process bilirubin effectively, causing a buildup in the body. Even though renal tissue has the highest level of GGT, the enzyme present in the serum appears to originate primarily from the hepatobiliary system, and GGT activity is elevated in any and all forms of liver disease. (An important aside: it’s nice when pancreatic carcinomas announce themselves this way, because it may allow for earlier detection of the tumor. If a red-top tube is used, transfer separated serum to a plastic transport tube. Bilirubin, Fractionated Test Detail Quest Diagnostics. Fractionated bilirubin can function as a multipurpose lab test to indicate various diseases of the liver or disease that affects the liver. Testing for fractionated bilirubin includes testing for total bilirubin, direct bilirubin, and indirect bilirubin. Keywords: fractionated bilirubin. in adults, raised bilirubin is usually predominantly conjugated. Elevated bilirubin in children or adults, however, strongly suggests a medical condition that must be investigated and treated. Expected Turnaround Time. If TSB is indicated, the first level should be fractionated to rule out direct hyperbilirubinemia. Serum 25-OHD (not 1,25-OH 2D), PTH, fractionated (bone-specific) alkaline phosphatase activity may be considered, but difficult to identify normal values. Bilirubin is NOT normally present in urine. Hyperbilirubinemia is a well-known condition in the clinical setting; however, the causes of elevated serum bilirubin are diverse, as are the clinical ramifications of this condition. • total bilirubin is about 3 mg/dl, direct bilirubin is about 0.3mg/dl! Consider DDx: a. Conjugated – biliary atresia, hepatitis (HSV? When bilirubin is elevated and all other liver tests are normal, bilirubin needs to be fractionated to evaluate for the predominant component that is elevated (conjugated versus unconjugated bilirubin). The measurement of fractionated bilirubin by Ektachem film slides. None presented a conjugated hyperbilirubinemia (DB/TB ratio >70%). Unconjugated bilirubin still produces Azobilirubin whereas conjugated bilirubin only produces it if dye is added. Presence of bilirubin implies Conjugated hyperbilirubinemia. The question, asked only to physicians, was “When do you request a conjugated bilirubin assay in a jaundiced newborn?” The answers are represented in Table 3. Most of the patients had graft-vs-host disease and various degrees of hepatic cholestasis as evidenced by … A total bilirubin (TSB or TcB) level should be measured on all newborns prior to discharge. 3. On occasion, hemolysis interferes with some assays and may result in a falsely elevated conjugated fraction. This assay uses LC/MS-MS to quantify the free acid, glycine-conjugate and taurine-conjugate forms of cholic acid, chenodeoxycholic acid, deoxycholic acid, and ursodeoxycholic acid. Your doctor may suspect Gilbert's syndrome if you have unexplained jaundice or if the level of bilirubin is elevated in your blood. Methodology. Indirect bilirubin is the unconjugated form of the substance and it is fat-soluble meaning that it can dissolve in lipids however; the direct or conjugated form is water-soluble. The fraction of the bilirubin, conjugated with glucuronic acid in the liver to form bilirubindiglucuronide is called conjugated bilirubin. This is normal and safe to use. High levels of bilirubin can cause jaundice, which is a yellowing of the eyes of skin. It can also give levels of two different types of bilirubin: unconjugated and conjugated. Conjugated bilirubin levels up to 2 mg/dL are found in infants by one month of age, and this will remains through adult life. This information can easily be obtained due to preexisting policy of testing total bilirubin in this time-frame. (a) Immunoblotting analyses for K48-linked Ub-prs (K48-Ub-prs. •Highlight the … The bilirubin should be fractionated one time to ensure that the hyperbilirubinemia is unconjugated rather than mixed. Those with any abnormal direct bilirubin or conjugated bilirubin had a 2nd stage screening at 2 weeks of life. Because humanized anti-CD22 epratuzumab can be given repeatedly, a single-center study was conducted to establish the feasibility, safety, … Conjugated and unconjugated bilirubin are separated out when "fractionation or differentiation" of the total bilirubin to its direct and indirect parts is request4ed from the laboratory. Bilirubin Blood Test: High vs. Low Levels, Direct vs. Phase 3 … Direct bilirubin >15% suggests a process in “conjugative & excretory” phases such as Dubin-Johnson Syndrome or Rotor syndrome, the former being due to mutations in MRP2. Bilirubin, conjugated 44.5% BV Bilirubin, conjugated ± 3 up to 15 µmol/L; 20% > 15 µmol/L RCPA Bilirubin, conjugated, neonatal ± 3 up to 15 µmol/L; 20% > 15 µmol/L RCPA Bilirubin, direct 0.4 mg/dL or 20% AAB Bilirubin, direct 20% or 0.4 mg/dL (greater) CAP, WLSH Bilirubin, direct 0.50 CFX Bilirubin, neonatal 0.31 CFX It is sometimes useful to determine the fraction of total serum bilirubin that is unconjugated versus that which is conjugated, usually referred to as fractionation of bilirubin. BAFS : Bile acids are formed in the liver from cholesterol, conjugated primarily to glycine and taurine, stored and concentrated in the gallbladder, and secreted into the intestine after the ingestion of a meal. Measurements of serum bilirubin should always be fractionated into unconjugated (indirect) or conjugated (direct) hyperbilirubinemia (1A). The jaundice associated with infection was moderate (17.9± 5.7 mg/dl). Targeted agents are increasingly used for the therapy of acute myeloid leukemia (AML). It enters the bile and passes from the liver to the small intestines and is eventually eliminated in the stool. Diagnosis People with GS predominantly have elevated unconjugated bilirubin, while conjugated bilirubin is usually within the normal range and is less than 20% of the total. Hyperbilirubinemia Differential Diagnosis: Bilirubin is a yellow colored pigment that the liver produces when red blood cells are broken down and recycled. Explanation of test results: As red blood cells age, they are broken down naturally in the body. Serum P, conjugated bilirubin/other liver function tests. The fraction of the bilirubin, not conjugated in the liver is called unconjugated bilirubin. Elevated total serum bilirubin levels should be fractionated to direct and indirect bilirubin fractions and an elevated serum conjugated bilirubin implies hepatocellular disease or biliary obstruction in most settings. Methods: The authors sought to have all infants have a fractionated bilirubin within the first 60 hours of life. The difference between Gilbert's syndrome and the control groups with normal or elevated serum bilirubin was highly significant (p less than 0.001). Bilirubin is NOT normally present in urine. Send thanks to the doctor. Bilirubin, Fractionated. Direct bilirubin = Conjugated bilirubin + delta bilirubin. A Bilirubin test is used to detect increase level in the blood. Much of it goes into the bile and thus out into the … [I-C*] Choose appropriate test for bilirubin levels (Table 4). • Fractionated bilirubin • Unconjugated hyperbilirubinaemia: Gilbert’s, hemolysis • Conjugated: Hepatitis A/B, EBV, CMV, auto-immune hepatitis, gallstones, toxins, drugs, metabolic disorders • Liver function tests AST/ALT/ALP/GGT • Hepatitis studies • S and u-copper, s-ceruloplasmin • Evaluate function liver: alb, INR, NH3, glucose

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