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Liver

Total bilirubin: what the breakdown product does and what a raised level means

Bilirubin is a yellowish substance that, according to MedlinePlus, the patient site of the US National Library of Medicine, is made during the normal breakdown of old red blood cells. According to the NVKC, the Dutch society of clinical chemists, the liver converts this substance into conjugated bilirubin, which leaves the body through the gut and the stools. On the way, bilirubin is found in bile, according to MedlinePlus a fluid the liver makes to help digest food.

When the liver is damaged or the bile ducts are blocked, bilirubin can leak out of the liver into the blood, according to MedlinePlus. Too much bilirubin in the blood can cause jaundice, in which the skin and the eyes turn yellow. According to MedlinePlus, a low level is usually not a cause for concern. Only a blood test shows how much bilirubin is in the blood.

For men older than 18, Star-SHL and Certe use an upper limit of 24 µmol/l; for women older than 18, their limit is 19 µmol/l. Unilabs gives 3 to 20 µmol/l for everyone from one month to 115 years and Diagnostiek voor U also 3 to 20 µmol/l for everyone older than 5 days, with no difference between men and women.

Doctor's Assessment Included

Bilirubin is the yellow breakdown product of red blood cells, which the liver processes and removes through the bile. For adults, Star-SHL and Certe use an upper limit of 24 µmol/l for men and 19 for women, Unilabs and Diagnostiek voor U 20 for everyone.

  • Total bilirubin is the sum of an unprocessed (indirect) form and a form processed by the liver (direct); a raised unprocessed form is usually due to red cell breakdown or Gilbert's syndrome, a raised processed form usually to liver disease or blocked bile ducts.
  • For an isolated raised bilirubin, with otherwise normal liver tests, the British Society of Gastroenterology (BSG) advises repeating the liver tests on a fasting sample, with a full blood count and direct and indirect bilirubin; in Gilbert's syndrome, total bilirubin then rises further.
  • A bilirubin result depends strongly on the measuring method, which is why limits differ between laboratories.

Reference Ranges

See the value that applies to you:

Choose male or female — this range differs by sex.

Enter your age — this range changes with age.

This range also depends on context such as cycle phase or sample material; the highlighted rows apply to your group.

Your reference range
umol/l
2 29 umol/l
Reference ranges by group, in umol/l
Male · 1–5 years 2–11 umol/l
2 11
Male · 6–12 years 3–16 umol/l
3 16
Male · 13–18 years 4–29 umol/l
4 29
Male · 19 years and older 4–24 umol/l
4 24
Female · 1–5 years 2–10 umol/l
2 10
Female · 6–12 years 3–16 umol/l
3 16
Female · 13–18 years 3–22 umol/l
3 22
Female · 19 years and older 3–19 umol/l
3 19
2 29 umol/l

Source: NVKC Reference population: Dutch general-practice population (NUMBER, n = 7,574,327)

Reference ranges may vary between laboratories. When you order a test, a BIG-registered doctor assesses your personal results in context. For treatment decisions, discuss your results with your GP.

Check your own value

Bilirubin (Total): what Dutch laboratories use

Reference ranges by group, in umol/l
Star-shl · Male · 19 years and older 4–24 umol/l
4 24
Star-shl · Female · 19 years and older 3–19 umol/l
3 19
Unilabs · Everyone · 0–115 years 3–20 µmol/l
3 20
Certe · Male · 18 years and older · a limit, not a range < 24 umol/L
24
Certe · Female · 18 years and older · a limit, not a range < 19 umol/L
19
Diagnostiek voor U · Everyone · 0 years and older 3–20 µmol/L
3 20
0 26.4 umol/l

Source: Star-shl

Source: Unilabs

Source: Certe

Source: Diagnostiek voor U

Each value as the laboratory itself publishes it, retrieved in 2026.

Bilirubin (Total): what this test measures

The total bilirubin test measures how much bilirubin is in the blood, in micromoles per litre (µmol/l). According to the British guideline on abnormal liver blood tests of the BSG, the British Society of Gastroenterology, total bilirubin is the sum of two forms: unconjugated bilirubin, which the liver has not yet processed, and conjugated bilirubin, which the liver has made soluble so that the body can excrete it. When either form rises, the total rises too, according to the BSG.

According to the NVKC, a bilirubin result depends strongly on the measuring method used, which is why reference values differ between laboratories. Unilabs lists a diazo reaction as its method and Star-SHL a photometric method. Unilabs asks for the blood tube to be kept in the dark as much as possible and protected from light.

Bilirubin (Total): why this value matters

According to the BSG, total bilirubin says something about how well the liver works, whereas liver enzymes mainly say something about the damage being done to the liver at that moment. The NVKC gives checking whether someone has jaundice as the reason for the test, a jaundice that can be caused by liver diseases and gallstones among other things.

According to MedlinePlus, a raised bilirubin can also fit haemolytic anaemia, a condition in which the body breaks down red blood cells faster than it makes them. According to MedlinePlus, a bilirubin test is only one measure of the health of the liver.

Bilirubin (Total): how the blood test works

Referral
No GP referral needed. After the order we arrange the referral through ZorgDomein, within one business day; orders after 17:00 or at the weekend start on the next business day. ZorgDomein emails a barcode, and that barcode is what the draw site needs.
The draw
A blood draw from a vein in the arm, at a partner laboratory's draw site. No home kit, no finger prick.
Which test
Liver checkup · €89,-
Where
650+ draw sites run by independent laboratories across the Netherlands. Draw sites

Bilirubin (Total): when is testing worthwhile?

According to the NVKC, a doctor usually requests a total bilirubin test together with other liver function tests, in someone with signs of liver problems such as yellow skin or yellow whites of the eyes. According to the NVKC, this also happens when a doctor suspects liver problems from heavy alcohol use or from poisoning by medicines. MedlinePlus also names dark urine, clay-coloured stools and stomach pain as symptoms for which a doctor may order the test.

For the bilirubin test, a doctor may ask you to fast for several hours or to stop certain medicines for a while, according to MedlinePlus. According to MedlinePlus, do not stop a medicine unless your doctor tells you to.

Bilirubin (Total): symptoms of a high or low value

Low Levels

According to MedlinePlus, a low total bilirubin is usually not a cause for concern. According to MedlinePlus, a low level may be due to medicines such as antibiotics, birth control pills, sleeping pills and medicines for seizures. Star-SHL gives a lower limit of 4 µmol/l for men older than 18 and 3 µmol/l for women older than 18, Unilabs gives 3 µmol/l for everyone from one month to 115 years and Diagnostiek voor U 3 µmol/l for everyone older than 5 days.

High Levels

According to MedlinePlus, a raised total bilirubin may be due to haemolytic anaemia, liver disease or a blockage in the bile ducts, the tubes that carry bile from the liver. In children and adults, the NVKC names among other things an inflammation of the liver, damage to the liver tissue, gallstones, long-term alcohol use and poisoning by medicines. According to the BSG, the most common cause of an isolated raised bilirubin, with no other abnormal liver tests, is Gilbert's syndrome, an inherited disorder of metabolism that according to the BSG is not linked to liver disease or ill health.

According to MedlinePlus, too much bilirubin in the blood can cause jaundice, in which the skin and the whites of the eyes turn yellow. Other symptoms for which MedlinePlus names the test are dark urine, clay-coloured stools and stomach pain, and according to MedlinePlus these could point to hepatitis, an inflammation of the liver, or to another liver disease.

Bilirubin (Total): causes of a low or high value

What lowers the value

  • Certain medicines

    A low bilirubin is usually not a cause for concern, but may be due to medicines such as antibiotics, birth control pills, sleeping pills and medicines for seizures.

What raises the value

  • Gilbert's syndrome

    The most common cause of an isolated raised bilirubin is Gilbert's syndrome, an inherited trait that 5 to 8 percent of people have and that is not linked to liver disease.

  • Breakdown of red blood cells

    A slightly raised bilirubin is found when red blood cells break down, as in haemolytic anaemia, and with large bruises.

  • Liver disease

    Hepatitis, damage to the liver tissue, long-term alcohol use or poisoning by medicines can raise bilirubin.

  • Blocked bile ducts

    Gallstones, a tumour of the bile ducts or pancreatic cancer that blocks the flow of bile can raise bilirubin.

  • Strenuous exercise

    Bilirubin can rise after strenuous exercise.

Bilirubin (Total): lifestyle and this value

An abnormal total bilirubin is one to discuss with your GP. If a doctor thinks there may be a liver disease or a red blood cell disorder, further tests may be needed according to MedlinePlus, such as other liver function tests, a urine test or an ultrasound. For an isolated raised bilirubin, the BSG advises repeating the liver tests on a fasting blood sample, with a full blood count and a separate measurement of direct and indirect bilirubin. In Gilbert's syndrome, total bilirubin should then rise further because of the indirect form, according to the BSG, and according to the BSG someone with the syndrome should be fully reassured.

Bilirubin (Total): frequently asked questions

What is Gilbert's syndrome?

According to the BSG, Gilbert's syndrome is an inherited disorder of metabolism in which the liver converts bilirubin less well, because the enzyme that does this conversion is less active. According to the BSG, 5 to 8% of the population has the syndrome, and according to the BSG it is not linked to liver disease or ill health. According to MedlinePlus Genetics, Gilbert's syndrome is usually recognised in adolescence.

Why does the upper limit differ between laboratories?

The upper limit of total bilirubin differs between laboratories because, according to the NVKC, the result depends strongly on the measuring method. Star-SHL and Certe give 24 µmol/l for men older than 18 and 19 µmol/l for women older than 18, Unilabs 20 µmol/l for everyone from one month to 115 years, Diagnostiek voor U 20 µmol/l for everyone older than 5 days, and the NVKC gives "tot 17 µmol/L" (up to 17 µmol/L) in its own table for children older than one month and adults. According to the NVKC, bilirubin is slightly higher in men than in women.

Why is bilirubin measured in newborns?

Bilirubin is measured in newborns because, according to the NVKC, the liver is not yet fully active at birth. According to MedlinePlus, many healthy babies get jaundice, which is usually not harmful and clears up within a few weeks. According to the NVKC, if bilirubin stays very high, brain damage can occur, which is why newborns are often placed under a UV lamp.

Bilirubin (Total): sources

  1. den Elzen WPJ, Brouwer N, Thelen MH, Le Cessie S, Haagen I-A, Cobbaert CM. NUMBER: standardized reference intervals in the Netherlands using a 'big data' approach. Clin Chem Lab Med 2018;57(1):42-56. (retrieved 2026) doi.org
  2. Star-shl, Labbepalingen (referentiewaarden per bepaling), star-shl.nl, geraadpleegd 2026-10-01 (retrieved 2026) star-shl.nl
  3. Unilabs, Bepalingenklapper (referentiewaarden per bepaling), bepalingenklapper.nl, geraadpleegd 2026-10-01 (retrieved 2026) bepalingenklapper.nl
  4. Certe, Bepalingenwijzer (referentiewaarden per bepaling), bepalingenwijzer.certe.nl, geraadpleegd 2026-10-01 (retrieved 2026) bepalingenwijzer.certe.nl
  5. Diagnostiek voor U, eLabgids (Referentiewaarden DvU), diagnostiek.getincontrol.eu, geraadpleegd 2026-10-01 (retrieved 2026) diagnostiek.getincontrol.eu
  6. MedlinePlus, Bilirubin Blood Test, U.S. National Library of Medicine, geraadpleegd 2026-10-13 (retrieved 2026) medlineplus.gov
  7. Newsome PN, et al. Guidelines on the management of abnormal liver blood tests. Gut 2018;67(1):6-19. (retrieved 2026) pmc.ncbi.nlm.nih.gov
  8. NVKC, Alles over testen: Bilirubine, allesovertesten.nl, geraadpleegd 2026-10-13 (retrieved 2026) allesovertesten.nl

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Bilirubin (Total)

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