Bilirubin, Total

TOTAL BILIRUBIN

Bilirubin comes from the breakdown of hemoglobin and is the byproduct of hemolysis. Bilirubin is produced by the RE portion of the liver and is excreted with the bile.
Pathologically elevations in total bilirubin occur when there is a massive amount of destruction of RBC’s, or the liver is congested and unable to excrete bilirubin.

From a physiologic perspective, the components of bile are inositol, choline, lecithin, cholesterol, and bilirubin/biliverdin. Cholesterol, which is produced by the liver, is converted into bile salts via the influence of the adrenal glands.
The bile salts are converted into cholic acid or chenodeoxycholic acid equally. Approximately 60 percent of all cholesterol is converted into these two acids.
These acids then combine with glycine and taurine to form glyco and tauro conjugated bile acids. The salts of these acids are secreted in the bile.
These salts do two things:
1. They act like "soap" creating saponification and emulsification of fat. This decreases the surface tension of the fat allowing agitation to break the fat up into smaller sizes.
2. Bile salts help absorb fatty acids, monoglycerides, cholesterol, and other lipids, by
forming minute complexes called micelles. Micelles are highly soluble, highly charged, and easily absorbed, increasing absorption by 40 percent.
The liver secretes about 600-1,200 milliliters of bile per day.
The purpose of bile is to:
1. Digest, emulsify and absorb fats.
2. To excrete waste products, such as excessive cholesterol, and bilirubin, which is the end product of hemoglobin degradation.
Bilirubin is the predominant pigment of bile, and is formed from hemoglobin, and destroyed red blood cells. The red blood cells are destroyed by the reticulo-endothelial system (liver and spleen), including the kupfer cells of the liver.
If the spleen/liver are hyperactive, the bile production is increased.
This allows the passive function of bile production to elevate.

As the spleen, liver, and bone marrow destroy hemoglobin it passes into the bloodstream with a protein creating a colloidal state. This creates hemolytic jaundice when there is excessive destruction or impaired production of red blood cells, leading to excessive amounts of prehepatic bilirubin.
The liver cells are unable to withdraw the bilirubin from the blood as fast as it is formed. Therefore consequently there is an increase in prehepatic bilirubin (indirect form).
Remember total bilirubin = the direct and indirect forms.
The direct is elevated in biliary obstruction, which is conjugated and reacted on by the liver.
The indirect form is elevated in liver failure, which is unconjugated and not reacted on by the liver.
Since the liver, spleen, adrenals and diet play a role in total bilirubin production from a physiologic perspective we must evaluate those glands as well.