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Q. Can you explain bilirubin and what the normal score should be on blood tests? I don't have my most recent blood work results handy, but I am always told that my bilirubin count is out of range and my red blood cell count is low.

I take 1 cc of B12 every two weeks, but it's not helping. Should I be eating more red meat or taking supplemental iron? I am a 54-year-old woman in otherwise good condition. I do have frequent fatigue and signs of anemia.

-- N.N.
A. During the process of removing old or damaged red blood cells (RBCs) from circulation, hemoglobin, the part of RBCs that carries oxygen, is broken down into bilirubin. Bilirubin is carried to the liver and excreted into the intestine as a component of bile to help with digestion.

Bilirubin is a reddish pigment product. Too much bilirubin in the skin results in jaundice and too much bilirubin in the urine results in dark urine. The stool is sometimes pale because of the relative lack of bilirubin pigment in the intestine.

The "normal" range of total serum (the liquid part of blood) bilirubin is 0.2-1.2 milligrams per decaliter. When bilirubin levels exceed 3.0 mg/dL, jaundice may be seen.

Abnormally high levels of bilirubin in the blood (called hyperbilirubinemia) can be due to abnormalities in the formation, transport, metabolism or excretion of bilirubin. For example, high levels of bilirubin may be caused by a blockage that obstructs the outflow of bile.

A serious concern about high serum bilirubin test results is the possibility of hemolytic anemia and liver damage. Hemolytic anemia can cause bilirubin levels in serum to be as high as 4.0 mg/dL. Anything higher may indicate some degree of liver damage.

As you know, anemia is the abnormally low count of RBCs, and it can be caused by excessive bleeding, decreased RBC production or increased RBC destruction (hemolysis). When the destruction of RBCs exceeds production, the result is hemolytic anemia.

Hemolytic disorders are classified as being intrinsic to the red blood cell or due to external (extrinsic) factors. Intrinsic factors can occur in any component of the red blood cell, including the cell wall and cell contents. Most of these disorders are inherited.

Most hemolytic anemias caused by extrinsic factors are due to immune system problems or drug toxicity.

Your symptoms are classic for anemia but are also associated with liver damage. You may indeed have one or both of these conditions. It's hard to tell without knowing more, e.g., how high your serum bilirubin levels are and for how long.

I think you should get a comprehensive blood workup done, together with a full range of liver function tests, and then discuss with your doctor the implications of the test results in terms of your particular situation. Be sure you get answers to all your questions.

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