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Bilirubin levels went down and are now up
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Bilirubin levels went down and are now up

I had jaundice in May this year due to hepatitis A and I healed pretty quickly as I went down to a very strict schedule of not drinking , not smoking and a zero fat diet. I even started going to the gym.

My levels for bilirubin and SGPT kept going down after that and on 31st July 2012 were down to:
Total - 1.1 mg/dl
Direct - 0.4 mg/dl
Indirect -0.7 mg/dl
SGPT - 34 IU/L

I am still not drinking and not smoking although I have introduced fat in my diet starting from August.
I got a sonography done yesterday and I was diagnosed with Grade-1 Fatty Liver.
I have had no discomfort related to it though.
Just to be sure , I got some blood tests done. My cholesterol, haemoglobin (is at 16) etc is perfectly within range.
So is my blood sugar.
However my bilirubin levels are now so:

Total - 1.7 mgdl
Direct - 0.5 mg/dl
Indirect - 1.2 mg/dl
SGPT - 9 IU/L

Need advice related to this. Are these levels due to me introducing fat in my diet again?
Does it mean that I have to still be careful related to my jaundice as my liver cant still take the hit of heavy food?
Or is it something else that I need to be worried about?
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Avatar_m_tn
First let me explain a little about bilirubin.

We see elevated bilirubin in patients with liver disease. Frequently bilirubin is seen on our lab results as TOTAL BILIRUBIN.
Total bilirubin = direct bilirubin + indirect bilirubin.
Generally an elevation of direct (also called conjugated bilirubin) suggests a possible liver or biliary tract issue. It could also be due to a gallstone blocking a bile duct.
On the other hand when the elevation is in the indirect or unconjugated bilirubin it does not usually suggest a liver problem.
An elevation of indirect bilirubin can be caused by several disorders. Hemolysis can cause an increased indirect bilirubin. In hemolysis red blood cells are prematurely destroyed and release bilirubin into the blood. Hemolysis may have a genetic aspect or it may be drug induced. Certain medication can destroy red blood cells which may result in an elevated indirect bilirubin. If this were the case one might expect to see a low hemoglobin (because of the red blood cell destruction) although that is not always the case. It is something that might be considered.
Elevated indirect bilirubin may also be due to Gilbert's Syndrome which most doctors believe to be a benign disease due to an decreased activity of an enzyme and I really don't understand the chemistry of the disorder. It is widely believed that Gilbert's Syndrome is harmless. Gilbert's is not that uncommon of a disease.

Your most recent labs - specifically your bilirubin - shows that your indirect bilirubin is significantly more elevated than is your direct bilirubin. In fact, depending on your lab's reference range your direct bilirubin may be just slightly out of range. My reference range shows .4 as the upper limit so your .5 would be barely out of range. Your indirect bilirubin is really the main cause in the elevation seen in your total bilirubin.

Since your direct bilirubin is just barely out of range I would ask my doctor if a diagnosis of Gilbert's Syndrome has been considered.

Non Alcoholic Fatty Liver Disease(NAFLD) in rather common these days - affecting perhaps 20% of the population. Generally people live long and productive lives with NAFLD but it can progress and develop into Non Alcoholic Steatohepatitis (NASH) which can be quite serious and can develop into cirrhosis. This occurs in roughly 2 to 5% of the population.

Interestingly, I came across this article which notes an association with NAFLD and elevated indirect bilirubin. Fortunately it appears that this association may be beneficial in NAFLD patients.

"Unconjugated hyperbilirubinemia in patients with non-alcoholic fatty liver disease: a favorable endogenous response.
Kumar R, Rastogi A, Maras JS, Sarin SK.
Source

Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi-110070, India. ***@****
Abstract

The clinical significance of increased frequency of unconjugated hyperbilirubinemia in patients with non-alcoholic fatty liver disease (NAFLD) is unknown. Serum bilirubin is an endogenous anti-oxidant, and oxidative stress plays an important role in the pathogenesis of NAFLD. In this study, we have documented 25.4% prevalence of unconjugated hyperbilirubinemia in 204 consecutive NAFLD patients. These patients had a significantly less severe liver disease on histopathology and/or fibroScan which may be attributed to anti-oxidant effect of bilirubin."

See: http://www.ncbi.nlm.nih.gov/pubmed/22198578

Another similar article appears below>

Unconjugated hyperbilirubinemia is inversely associated with non-alcoholic steatohepatitis (NASH).
Hjelkrem M, Morales A, Williams CD, Harrison SA.
Source

Brooke Army Medical Center, Gastroenterology Service, Fort Sam Houston, TX, USA.
Abstract
BACKGROUND:

It has been recognised that unconjugated bilirubin contains hepatic anti-fibrogenic and anti-inflammatory properties and is a potent physiological antioxidant cytoprotectant. We believe that unconjugated hyperbilirubinemia may protect against development of non-alcoholic steatohepatitis (NASH).
AIM:

This study was conducted to assess the association of serum unconjugated bilirubin levels and histological liver damage in non-alcoholic fatty liver disease (NAFLD).
METHODS:

This was a retrospective analysis involving adult patients from a tertiary medical centre undergoing liver biopsy to evaluate suspected NAFLD or NASH and a control group without NAFLD based on normal liver ultrasound, labs and history. Identification of unconjugated hyperbilirubinemia was based on the presence of predominantly unconjugated bilirubin ≥1.0 mg/dL (17.1 μmol/L) while fasting, in the absence of haemolytic disease or other hepatic function alteration.
RESULTS:

Six-hundred and forty-one patients were included. Unconjugated hyperbilirubinemia was inversely associated with NASH (OR 16.1, 95% CI 3.7-70.8 P < 0.001). Of the patients without NAFLD (133 patients), 13 (9.8%) had unconjugated hyperbilirubinemia (range 1.0-1.8, mean 1.4). Of the patients with NAFLD without NASH (285 patients), 32 (11.2%) had unconjugated hyperbilirubinemia (range 1.0-3.0, mean 1.4). Of the patients with NASH (223 patients), three (1.3%) had unconjugated hyperbilirubinemia (1.0, 1.1, 1.4).
CONCLUSIONS:

Unconjugated hyperbilirubinemia is inversely associated with the histopathological severity of liver damage in non-alcoholic fatty liver disease.

Published 2012. This article is a US Government work and is in the public domain in the USA.

See:http://www.ncbi.nlm.nih.gov/pubmed/22540836

If I were you I would try to limit my fat intake. If you are overweight it would be wise to try and lose some weight and also maintain a regular exercise routine. There are no drugs to treat NAFLD at this time. There is some evidence that vitamin e can be beneficial in some patients but this has not be proven to my satisfaction. You should probably review any medications you are taking with your doctor in light of your diagnosis of NAFLD.

Good luck,
Mike
4 Comments Post a Comment
Blank
Avatar_m_tn
First let me explain a little about bilirubin.

We see elevated bilirubin in patients with liver disease. Frequently bilirubin is seen on our lab results as TOTAL BILIRUBIN.
Total bilirubin = direct bilirubin + indirect bilirubin.
Generally an elevation of direct (also called conjugated bilirubin) suggests a possible liver or biliary tract issue. It could also be due to a gallstone blocking a bile duct.
On the other hand when the elevation is in the indirect or unconjugated bilirubin it does not usually suggest a liver problem.
An elevation of indirect bilirubin can be caused by several disorders. Hemolysis can cause an increased indirect bilirubin. In hemolysis red blood cells are prematurely destroyed and release bilirubin into the blood. Hemolysis may have a genetic aspect or it may be drug induced. Certain medication can destroy red blood cells which may result in an elevated indirect bilirubin. If this were the case one might expect to see a low hemoglobin (because of the red blood cell destruction) although that is not always the case. It is something that might be considered.
Elevated indirect bilirubin may also be due to Gilbert's Syndrome which most doctors believe to be a benign disease due to an decreased activity of an enzyme and I really don't understand the chemistry of the disorder. It is widely believed that Gilbert's Syndrome is harmless. Gilbert's is not that uncommon of a disease.

Your most recent labs - specifically your bilirubin - shows that your indirect bilirubin is significantly more elevated than is your direct bilirubin. In fact, depending on your lab's reference range your direct bilirubin may be just slightly out of range. My reference range shows .4 as the upper limit so your .5 would be barely out of range. Your indirect bilirubin is really the main cause in the elevation seen in your total bilirubin.

Since your direct bilirubin is just barely out of range I would ask my doctor if a diagnosis of Gilbert's Syndrome has been considered.

Non Alcoholic Fatty Liver Disease(NAFLD) in rather common these days - affecting perhaps 20% of the population. Generally people live long and productive lives with NAFLD but it can progress and develop into Non Alcoholic Steatohepatitis (NASH) which can be quite serious and can develop into cirrhosis. This occurs in roughly 2 to 5% of the population.

Interestingly, I came across this article which notes an association with NAFLD and elevated indirect bilirubin. Fortunately it appears that this association may be beneficial in NAFLD patients.

"Unconjugated hyperbilirubinemia in patients with non-alcoholic fatty liver disease: a favorable endogenous response.
Kumar R, Rastogi A, Maras JS, Sarin SK.
Source

Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi-110070, India. ***@****
Abstract

The clinical significance of increased frequency of unconjugated hyperbilirubinemia in patients with non-alcoholic fatty liver disease (NAFLD) is unknown. Serum bilirubin is an endogenous anti-oxidant, and oxidative stress plays an important role in the pathogenesis of NAFLD. In this study, we have documented 25.4% prevalence of unconjugated hyperbilirubinemia in 204 consecutive NAFLD patients. These patients had a significantly less severe liver disease on histopathology and/or fibroScan which may be attributed to anti-oxidant effect of bilirubin."

See: http://www.ncbi.nlm.nih.gov/pubmed/22198578

Another similar article appears below>

Unconjugated hyperbilirubinemia is inversely associated with non-alcoholic steatohepatitis (NASH).
Hjelkrem M, Morales A, Williams CD, Harrison SA.
Source

Brooke Army Medical Center, Gastroenterology Service, Fort Sam Houston, TX, USA.
Abstract
BACKGROUND:

It has been recognised that unconjugated bilirubin contains hepatic anti-fibrogenic and anti-inflammatory properties and is a potent physiological antioxidant cytoprotectant. We believe that unconjugated hyperbilirubinemia may protect against development of non-alcoholic steatohepatitis (NASH).
AIM:

This study was conducted to assess the association of serum unconjugated bilirubin levels and histological liver damage in non-alcoholic fatty liver disease (NAFLD).
METHODS:

This was a retrospective analysis involving adult patients from a tertiary medical centre undergoing liver biopsy to evaluate suspected NAFLD or NASH and a control group without NAFLD based on normal liver ultrasound, labs and history. Identification of unconjugated hyperbilirubinemia was based on the presence of predominantly unconjugated bilirubin ≥1.0 mg/dL (17.1 μmol/L) while fasting, in the absence of haemolytic disease or other hepatic function alteration.
RESULTS:

Six-hundred and forty-one patients were included. Unconjugated hyperbilirubinemia was inversely associated with NASH (OR 16.1, 95% CI 3.7-70.8 P < 0.001). Of the patients without NAFLD (133 patients), 13 (9.8%) had unconjugated hyperbilirubinemia (range 1.0-1.8, mean 1.4). Of the patients with NAFLD without NASH (285 patients), 32 (11.2%) had unconjugated hyperbilirubinemia (range 1.0-3.0, mean 1.4). Of the patients with NASH (223 patients), three (1.3%) had unconjugated hyperbilirubinemia (1.0, 1.1, 1.4).
CONCLUSIONS:

Unconjugated hyperbilirubinemia is inversely associated with the histopathological severity of liver damage in non-alcoholic fatty liver disease.

Published 2012. This article is a US Government work and is in the public domain in the USA.

See:http://www.ncbi.nlm.nih.gov/pubmed/22540836

If I were you I would try to limit my fat intake. If you are overweight it would be wise to try and lose some weight and also maintain a regular exercise routine. There are no drugs to treat NAFLD at this time. There is some evidence that vitamin e can be beneficial in some patients but this has not be proven to my satisfaction. You should probably review any medications you are taking with your doctor in light of your diagnosis of NAFLD.

Good luck,
Mike
Blank
Avatar_m_tn
Thanks a lot mike for the detailed reply.
Really appreciate it !

I guess I am just going to limit my fat intake and keep my diet restrictions as they were until July as I understand my liver is still not able to take the load.
Also, I have stopped drinks entirely since May and I plan to continue that stoppage. Not smoking either.
And yes, I shall keep doing my cardio at the gym to keep my weight issues at bay (I am 6'1" and 92 kgs, 26 years, so I am going to try to bring that down).

I guess after all this, it shouldn't be a problem as I mentioned that all my other reports are way in the normal range.
I guess that should do it, right?
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Avatar_m_tn
I think you're going to be fine if you stick to that regimen.

I wish you all the best.

Mike
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Avatar_m_tn
Thanks a ton again, Mike.
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