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Home » Bilirubinuria: Causes & Appearance of Bilirubin in Urine

Bilirubinuria: Causes & Appearance of Bilirubin in Urine

Bilirubin is not typically present in urine. When it appears in urine, it may or may not be detectable by eyes depending on its concentration. Mild bilirubinuria doesn’t change the urine appearance, while moderate to severe bilirubin may cause dark yellow to brown urine.

Here are some key facts from this article:

  • Bilirubin is a yellow-colored waste product that forms during the natural breakdown of red blood cells
  • Bilirubinuria is a condition where bilirubin is present in the urine, which can be a sign of liver dysfunction or other health problems that lead to increased red blood cell breakdown.
  • When bilirubin is present in the urine, it can alter the color of the urine.
  • Mild bilirubin in urine doesn’t change the urine’s appearance
  • Moderate bilirubin in urine may cause dark yellow to brown urine.
  • Severe cases may cause dark brown or cola-colored urine.
  • People with bilirubinuria may experience other symptoms, such as jaundice, abdominal pain, fatigue or general weakness, dark-colored stools, itching, nausea, and vomiting.
  • Several factors can lead to the presence of bilirubin in the urine, including liver diseases, hemolytic anemia, gallbladder diseases, genetic disorders, and medications.

What is bilirubin and bilirubinuria?

The yellow-hued byproduct, bilirubin, emerges from the breakdown of red blood cells.

The liver carries out the essential function of breaking down bilirubin, which is then removed from the body via urine and feces. In healthy individuals, the presence of bilirubin in urine is undetectable.

Bilirubinuria, however, indicates the presence of bilirubin in urine; the presence of bilirubin in urine often occurs with one or more of the following conditions (reference):

  • Obstruction of the bile ducts (by a gallstone, tumor, or narrowing).
  • Liver diseases: acute or chronic hepatitis, liver cirrhosis, or immune-related liver and biliary disorders can all cause bilirubinuria (bilirubin in urine). Also, some medications may cause increased bilirubin (via affection of the liver) and the subsequent appearance of bilirubin in urine).
  • Break down of blood cells (hemolytic anemia, especially the intravascular types).
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Almost all cases of bilirubin in urine are accompanied by increased bilirubin levels in the blood (hyperbilirubinemia) which typically leads to jaundice (yellow skin and eye whites).

What does bilirubin in urine look like?

When bilirubin is present in the urine, it can alter the color of the urine if the concentration is high enough (dark yellow, orange, light brown, up to dark brown or cola-colored urine.

The severity of bilirubinuria can be divided into three categories based on the urine color:

A. Yellow (normal) urine in mild bilirubinuria

In cases of mild bilirubinuria, the urine may still appear yellow, similar to the color of normal urine. However, the shade might be slightly darker than usual.

B. Dark yellow (amber) urine in moderate bilirubinuria

The urine may look dark yellow or amber in color when moderate bilirubinuria occurs. This color change is due to a higher bilirubin concentration in the urine.

C. Brown (cola- or tea-colored) urine in severe bilirubinuria

In severe cases of bilirubinuria, the urine can become brown, cola-, or tea-colored. The high levels of bilirubin or urobilinogen present in the urine cause this darkening.

What other symptoms are associated with bilirubin in urine?

In addition to changes in urine color, people with bilirubinuria may experience other symptoms, such as:

  • Jaundice (yellowing of the skin and eyes)
  • Abdominal pain or discomfort
  • Fatigue or general weakness
  • Dark-colored stools
  • Itching, especially on the palms and soles
  • Nausea and vomiting
  • pallor.
  • Signs of liver cirrhosis, such as swollen limbs or

It’s essential to consult a healthcare professional if you experience any of these symptoms, as they could indicate an underlying health issue.

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Common causes of bilirubinuria: Why is there bilirubin in the urine?

Several factors can lead to the presence of bilirubin in the urine; here are the most common diseases and conditions that lead to bilirubin in urine.

  • Liver diseases: Conditions like hepatitis, cirrhosis, or liver cancer can cause bilirubinuria.
  • Hemolytic anemia: Increased breakdown of red blood cells can lead to higher bilirubin levels in the blood and urine.
  • Gallbladder diseases: Gallstones or inflammation of the gallbladder (cholecystitis) can obstruct bile flow and result in bilirubinuria.
  • Genetic disorders: Certain inherited conditions, like Gilbert’s syndrome or Crigler-Najjar syndrome, can interfere with bilirubin processing and cause it to appear in the urine.
  • Medications: Some drugs can affect liver function or increase red blood cell breakdown, leading to bilirubinuria.

The three main sources of bilirubin that appear in urine can be classified into prehepatic (breakdown of red blood cells), hepatic (liver diseases and conditions), and post-hepatic (due to biliary obstruction).

The table below summarizes the main causes and their clinical features (reference):

Pre-hepaticHemolysis (increased breakdown of red blood cells)Fatigue, pallor, dark urine, splenomegaly (enlarged spleen), anemia, increased unconjugated (indirect) bilirubin
Examples: autoimmune hemolytic anemia, hereditary spherocytosis, glucose-6-phosphate dehydrogenase (G6PD) deficiency, sickle cell anemia
HepaticHepatocellular dysfunction (impaired liver function)Fatigue, weakness, weight loss, anorexia, nausea, vomiting, dark urine, light-colored stools, abdominal pain, hepatomegaly (enlarged liver), increased unconjugated (indirect) or conjugated (direct) bilirubin
Examples: viral hepatitis, alcohol-induced liver disease, non-alcoholic fatty liver disease, cirrhosis, drug-induced liver injury, Wilson’s disease, alpha-1 antitrypsin deficiency, Gilbert’s syndrome, Crigler-Najjar syndrome
Post-hepaticBiliary obstruction (blockage of bile ducts)Abdominal pain (biliary colic), dark urine, light-colored stools (clay-colored stools), pruritus (itching), fever, jaundice, increased conjugated (direct) bilirubin
Examples: choledocholithiasis (stones in the common bile duct), cholangitis (inflammation of the bile ducts), pancreatic head tumors, primary sclerosing cholangitis, Mirizzi syndrome, biliary atresia (in newborns)

Confirming and diagnosing the cause of bilirubin in urine?

To accurately diagnose the cause of bilirubin in urine, medical professionals follow a systematic approach that includes several steps (reference):

  • Medical history and physical examination: Collect information on symptoms, potential risk factors, and any relevant medical history.
  • Initial laboratory tests: Perform key tests to evaluate liver function and possible hemolysis, such as:
    • Complete blood count (CBC)
    • Liver function tests (LFTs)
    • Direct and indirect bilirubin measurements
  • Additional investigations: Depending on the initial findings and clinical presentation, supplementary tests may be required:
    • Imaging studies: Abdominal ultrasound, CT scan, or MRI to detect biliary obstruction or liver abnormalities.
    • Hemolysis assessment: Reticulocyte count, haptoglobin, lactate dehydrogenase (LDH), and peripheral blood smear for suspected hemolytic cases.
    • Viral hepatitis tests: Serologic tests to identify viral hepatitis infections.
    • Genetic testing: Investigate inherited conditions such as Gilbert’s syndrome or Crigler-Najjar syndrome.
    • Liver biopsy: In specific cases, a liver biopsy might be necessary for a comprehensive evaluation.
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Treatment options for bilirubinuria: How can it be managed?

Possible treatments depend on the original cause of bilirubin in urine; the treatment may involve:

  • Managing liver diseases: Health professionals may suggest lifestyle changes, medications, or even liver transplantation to address hepatitis, cirrhosis, or other liver conditions.
  • Treating hemolytic anemia: Various supportive measures may be required depending on the cause, including blood transfusions and iron supplementation.
  • Addressing gallbladder issues: In some cases, surgical removal of gallstones or the gallbladder itself may be necessary.
  • Adjusting medications: If medications are suspected to be the cause of bilirubinuria, healthcare providers may suggest adjusting the dosage or switching to a different drug.
  • Monitoring and follow-up: In some cases, regular monitoring is advised instead of specific treatment, such as with Gilbert’s syndrome.


Bilirubinuria can manifest in various shades of urine color, ranging from yellow to dark brown, depending on the severity. Identifying the cause of bilirubinuria is crucial for proper treatment and management.

If you suspect you have bilirubinuria or experience any of the symptoms mentioned above, it is better to consult your doctor for an accurate diagnosis and appropriate treatment plan.

And beware of the potential causes and symptoms of bilirubinuria can help individuals recognize when to seek medical attention, ultimately leading to better overall health and well-being.