Elevated bilirubin with no apparent cause: Gilbert’s syndrome?

Author: V. Dimov, M.D., University of Chicago
Reviewer: S. Randhawa, M.D.

An 82-year-old African American male (AAM) with a past medical history (PMH) of atrial fibrillation (Afib) on warafrin (Coumadin) for the last 3 years was admitted to the hospital with a chief complaint (CC) of neck pain for 7 days.

He had a similar episode of neck pain 5 months ago and was treated with antibiotics.

Physical examination

Afebrile with stable vital signs.
Furunculosis and cellulitis of the back of the neck.
CVS examination showed irregularly irregular rhythm.
The rest of the examination was unremarkable.

Complete blood count (CBC) and complete metabolic panel (CMP) during the last 6 months (left). Liver function tests (LFT), direct and indirect bilirubin (right) (click to enlarge the images).

The complete metabolic panel (CMP) showed an increase in total bilirubin mostly due to the indirect bilirubin. Patient was not visibly jaundiced, which is not surprising because jaundice is usually seen when the total bilirubin level is greater than 3 mg/dL.

The rest of the liver function tests (LFT) were within normal limits (WNL).

What is the most likely cause of elevated bilirubin in this patient?

Gilbert’s syndrome, which represents an asymptomatic increase in indirect bilirubin in a fasting patient or during an intercurrent infection. In this patient the infection was neck furunculosis.

Notice that there was a "bump" in the bilirubin level during the previous hospitalization for neck skin infection 5 months ago.

How do you treat Gilbert’s syndrome?

There is no treatment, and there is no need for one, hyperbilirubinemia typically resolves on its own.

Final diagnosis

Gilbert’s syndrome.

What did we learn from this case?

Not all laboratory changes are due to dangerous causes. Gilbert’s syndrome is a relatively common and benign entity.


Gilbert's Syndrome - eMedicine.
Gilbert’s syndrome - BMJ 10-Minute Consultation, 2011.

Related reading

Unconventional tennis player Dolgopolov has Gilbert's syndrome, a liver condition that can cause fatigue. WSJ, 2011.

Published: 02/12/2004
Updated: 09/05/2011

1 comment:

  1. An important diagnosis because of its absence of complications! Once you recognize Gilbert's an extensive workup can be avoided.

    Gilbert's often comes up during fasting labwork because it is a relative stress on the body. Repeating the bilirubin (both total and direct) when patient is not fasting will often show resolution of the hyperbilirubinemia.