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BENIGN HYPERBILIRUBINAEMIA
O P Kapoor
Hon. Visiting Physician, Jaslok Hospital and Bombay Hospital, Mumbai,
Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
In the last 40 years of my practice I have come across hundreds of patients of hyperbilirubinaemia incidentally detected and diagnosed as viral hepatitis. These patients are then told to go on a diet and lose weight. In fact, often "starving" raises bilirubin levels further. Initially, I used to try to label them as either Gilbert's disease or Dubin Johnson syndrome or BRIC (benign recurrent intra-hepatic cholestasis).
In Gilbert's disease, the bilirubin detected is of indirect type and the condition is quite common in normal population and calls for no treatment.
In Dubin Johnson syndrome - the bilirubin detected is that of direct reacting type.
Patients having BRIC come with complaints of pruritus and the blood test shows increased levels of direct reacting bilirubin and markedly raised alkaline phosphatase (liver fraction)or Gama GT.
All the above conditions are "benign". All I want to impress in this article is that none of these or "direct" reacting bilirubin. In fact, all the patients showed increased direct and indirect reacting bilirubin.
The fact is that at the lower blood levels of increased bilirubin, it is impossible to differentiate between direct and indirect and invariably the pathologist's reports are wrong.It is the pathologists who should wake up and do a routine urine test and then report the serumbilirubin levels. In case the urine shows bile pigments then the bilirubin is "direct" reacting.
In short, in Gilbert's disease, there will be no bilirubin in the urine. In Dubin Johnson urine shows bile pigments. In BRIO a predominant finding will be markedly raised Alkaline Phosphatase or Gama GT along with bile pigments in the urine.
I like the terminology of "benign hyperbilirubinaemia". All these patients should be told that their livers are normal!
In the past it has been taught that presence of sugar in the urine has no importance unless the blood sugar has been done at the same time.
Now it should be stressed that the report of serum bilirubin levels have no significance unless patients had a straight forward level of "indirect" the urine is tested for bile pigments. The report given along with this, will thus benefit thousands of patients in our population who are being labelled as patients having "liver" disease.
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