Typical & Atypical Bilirubin levels in cirrhosis.

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What are the typical bilirubin levels and liver cirrhosis?

Typically bilirubin levels are normal or slightly increased with liver cirrhosis. However, patients with advanced liver cirrhosis or acute complications may have significantly high bilirubin levels.

Cirrhosis is a result of many chronic liver diseases. Liver conditions that cause prolonged destruction and fibrosis of the liver tissue will ultimately end in cirrhosis.

But the process of cirrhosis is often slowly progressive. It starts with limited destruction of the liver tissues and its replacement with fibrous tissue.

In the early stages of liver cirrhosis, the liver functions (including bilirubin levels) are often normal. However, as cirrhosis progresses, the deterioration starts to roll out and progress over months or years.

The bilirubin levels in cirrhosis are variable depending on:

  • The stage of liver cirrhosis.
  • The presence of complications (such as acute on top of chronic liver failure).
  • The presence of other associated conditions such as bile duct stones or bile stricture.
  • The original cause of liver cirrhosis: for example, patients with cirrhosis secondary to primary biliary cholangitis may have higher bilirubin levels than others.

Why does bilirubin increase in patients with cirrhosis?

Bilirubin is an end product of the natural turnover process of your red blood cells. It results from the breakdown of hemoglobin found inside the red blood cells.

Also, bilirubin results from the breakdown of other molecules such as myoglobin (in muscles), cytochrome, and some other enzymes.

The liver is the main site of uptake, processing, and excretion of bilirubin. The liver contains an extensive network of very small (microscopic) bile canoanorectals that collects bilirubin from the liver cells and excretes it into bile.

In patients with liver cirrhosis, extensive liver tissue damage often results in the destruction and disruption of these small canoanorectals. As a result, the liver becomes partially unable to get rid of excess bilirubin.

Consequently, bilirubin concentrations increase in the body, and blood levels increase in cirrhosis patients.

However, in the early stages of liver cirrhosis, the disruption of the system of bile canoanorectals inside the liver is often very mild. Therefore, patients with the early stage of cirrhosis may have normal bilirubin levels.

Can bilirubin be normal liver cirrhosis?

Bilirubin can be entirely normal in patients with liver cirrhosis. However, the presence of normal bilirubin levels doesn’t exclude cirrhosis.

However, bilirubin is NOT a sensitive indicator of the severity of liver damage in liver cirrhosis (reference).

Bilirubin levels may be normal despite moderate to severe liver tissue damage in patients with cirrhosis and other inflammatory liver conditions.

Studies have demonstrated that a healthy liver can excrete up to 10 times the amounts of bilirubin that is normally excreted.

This reserve capacity of the liver explains why bilirubin levels are normal despite significant liver tissue damage in liver cirrhosis.

Can normal bilirubin rule out liver cirrhosis?

Normal bilirubin cannot be used to rule out liver cirrhosis. However, bilirubin remains normal in patients with liver cirrhosis in mild to moderate degrees.

The entire liver function tests (including bilirubin) can be normal in the early stages of liver cirrhosis.

The diagnosis of cirrhosis doesn’t rely on the lab derangements such as elevated bilirubin levels. But rather on visualizing the cirrhosis (advanced fibrosis) in the liver tissue by either imaging techniques or biopsy.


Normal bilirubin doesn’t always mean you don’t have liver cirrhosis. Instead, it may mean you have either a healthy (normal) liver or a compensated (mild) liver cirrhosis.

What causes high bilirubin levels in patients with liver cirrhosis?

Patients with liver cirrhosis may have chronic or acute elevations in their bilirubin levels:

  • Chronic elevations are often mild to moderate and are often caused by the progression of liver cirrhosis.
  • Sudden new elevation of bilirubin in cirrhotic patients often denotes a complication of liver cirrhosis or biliary disease.

What causes acute elevation of bilirubin in liver cirrhosis?

Sudden progressive rise of bilirubin in patients with liver cirrhosis can be caused by (main causes):

1. Acute on top of chronic liver failure:

The cirrhotic liver is vulnerable to complications. Many stressors such as infections, toxins, and low blood pressure. In such cases, the bilirubin levels in the cirrhotic liver may rise to a very high level (exceeding 10 mg/dL).

Acute on top of chronic liver failure is the most common cause of death in patients with liver cirrhosis.

2. Drugs:

Cirrhotic patients are often poly-medicated, and more than 1000 medications cause liver affection (reference).

Moreover, this cirrhotic liver is more likely to be affected by toxins and medications than a healthy liver.

So, medications should be on the top list of suspected causes of elevated bilirubin in patients with liver cirrhosis.

3. Reactivation of hepatitis:

Hepatitis may recur on top of liver cirrhosis due to reactivation of the previous infections (such as hepatitis B to C) or acquiring a new infection.

4. Associated obstruction of the bile ducts:

Bile duct obstruction due to a stone, tumor, or a stricture (narrowing) may cause a sudden progressive elevation in bilirubin levels in cirrhotic patients.

5. Liver cancer.

Patients with liver cirrhosis are at higher risk of liver cancer (hepatocellular carcinoma). More than 90% of the cases of hepatocellular carcinoma are associated with liver cirrhosis (reference).

Liver cancer may compress the small bile ducts inside the liver or cause liver decompensation leading to elevated bilirubin levels.

Went to worry about bilirubin levels in cirrhosis?

Bilirubin levels in liver cirrhosis are typically normal or mildly elevated (2-3 mg/dL). The elevation in bilirubin (if happens) is often stationary or very slowly progressive over months or years.

Rapid progressive rise of bilirubin (within days or weeks) often denotes complications such as acute on top of chronic liver failure or new episode of hepatitis.

When to worry about bilirubin levels in cirrhosis:

  • Sudden progressive rise in its levels within days or weeks.
  • Presence of severe liver pain or biliary colics.
  • Clay (pale) stools.
  • Your doctor should also investigate a new rise in previously normal bilirubin, even if it’s a mild rise.
  • Bilirubin rise after starting a new medication.
  • Associated fever or vomiting.
  • Associated marked elevation in liver enzymes (denoting an episode of hepatitis).
  • Associated kidney impairment or rise in serum creatinine.

How to lower bilirubin levels in cirrhosis.

Persistent bilirubin in patients with liver cirrhosis denotes an advanced stage. Lowering bilirubin levels in this condition depends on the optimal management of cirrhosis, avoidance of liver stressors, and dietary modifications.

Best tips to lower bilirubin in patients with liver cirrhosis:

  • Stop alcohol drinking.
  • Treatment of the original cause of liver cirrhosis (for example, treatment of hepatitis C or B is associated with better outcomes of liver cirrhosis).
  • Avoid toxins and hepatoxic medications.
  • Stay hydrated.
  • Avoid a high-fat and high-protein diet.
  • Instead, consume high-fiber, anti-oxidant fruits and vegetables.
  • Ask your doctor about Ursodeoxycholic acid (a medication that effectively lowers bilirubin in cirrhosis).
  • Liver support supplements such as selenium and vitamin E.
  • Liver transplantation (if indicated) is the best and definitive treatment of high bilirubin and liver cirrhosis.

MORE: Is it Normal to have a Small Trace of Bilirubin in Urine?