Bilirubin

What is being measured

Bilirubin is created when the red blood pigment breaks down. It accumulates in the spleen, liver and bone marrow, is initially insoluble in water and therefore travels bound to albumin Liver. There, an enzyme couples glucuronic acid to it, and only this coupled bilirubin can be excreted via the bile.

The finding therefore distinguishes three numbers, and the distinction is the entire information:

• Total bilirubin is the sum.
• Direct bilirubin is the already coupled share. It backs up when the drain blocks the bile.
• Indirect bilirubin is the portion that is not yet coupled. It builds up when there is a lot of activity or the coupling is running slowly.

Normally, the indirect portion accounts for over 90 percent of the total bilirubin. The direct portion above 2 mg/dl or more than 20 percent of the total value is considered pathological, and then it represents cholestasis, i.e. a disturbed flow of bile, or damage to the liver cells themselves.

The indirect bilirubin is often not printed specifically; it is the difference between total and direct. Anyone who only has the overall value in front of them does not yet know which of the two stories they are reading.

Reference range

• Total bilirubin 0.2 to 1.2 mg/dL
• Direct bilirubin up to 0.3 mg/dl
• Indirect bilirubin 0.1 to 0.9 mg/dL

These are conventions of laboratory medicine and not study findings. They differ depending on the measurement method, the area depends on your own findings. Expressed in µmol/l, the numbers are about seventeen times larger.

The most common cause is harmless

A slightly elevated total bilirubin is a common incidental finding. A common benign cause of mildly elevated unconjugated bilirubin is Gilbert's syndrome, usually called Meulengracht's disease in German-speaking countries; it is found in about 5 to 10 percent of the population.

This is based on a variant in the control region of the gene for the coupling enzyme. The more additional TA building blocks there are, the higher the bilirubin is in the blood, and in a study of 265 people, the mean increased with the number of variants present together: 82 percent of those affected carried four or more of them compared to 37 percent of the comparison people.

The pattern that suggests this is an exclusion pattern: mildly elevated indirect Bilirubin with normal transaminases, normal bile duct values and normal erythrocyte count. It alone does not allow a clear diagnosis. What is striking is that nothing else stands out. In practice it is reported that the value temporarily increases after fasting or an infection; This has not been examined in the works used here.

The two parts point in different directions

This is where things get unexpected. A slightly elevated indirect bilirubin is not only harmless, it is associated with fewer vascular diseases. A review article summarizes that people with mildly elevated unconjugated bilirubin are less likely to have coronary and peripheral vascular disease and, conversely, low levels are associated with an increased risk of coronary artery disease, independent of usual risk factors. The same review cites a lower incidence of cardiovascular disease and type 2 diabetes as well as lower mortality for Gilbert's syndrome.

This means that the value is no longer on a scale from good to bad. In the observation data used, a higher unconjugated proportion was associated with fewer vascular changes; the opposite direction was found for the conjugated one. A total bilirubin of 1.6 mg/dl suggests various causes depending on the breakdown; How urgent it is does not yet follow from this.

The serious case: cholestasis

Anabolic androgenic steroids can cause cholestasis; the exact mechanism has not been clarified in the work used here. What it looks like when it happens is described in 44 young men who developed liver damage after taking bodybuilding supplements. The mean age was 33 years and the median time to liver damage was 73 days. All 44 had a yellow discoloration, 84 percent suffered from itching, 71 percent were hospitalized. The cholestasis slowly resolved. Nobody died and nobody needed a new liver.

The last two sentences should be read together. The course is severe and the cholestasis slowly regressed; Nobody died in this series and nobody needed a transplant. It would be wrong to ignore both: the trivialization as well as the panic.

The spectrum extends further. In addition to cholestasis, a review article mentions peliosis hepatis as well as benign and malignant liver tumors and states that liver function normalizes after discontinuation in most cases with supportive treatment, but individual long-term effects do not go away.

Ursodeoxycholic acid is discussed as a treatment in the case report of such cholestasis. That's the bile acid that's also behind it TUDCA stands; The work does not provide reliable effectiveness data for this application.

What moves the value and what doesn't

The most important point for strength athletes is a non-finding. In a study of 15 healthy men accustomed to moderate exercise without resistance training, AST, ALT, LD, CK, and myoglobin increased significantly after one hour of weight lifting and remained elevated for at least seven days. Bilirubin, gamma-GT and alkaline phosphatase remained within the normal range.

The fact that the participants were not used to the training is part of the finding. Unusual stress causes more damage to the muscle than usual stress, and transaminases have increased significantly accordingly. The fact that the bilirubin did not go is more significant under this condition than it would be under light stress.

This results in the division of labor, which also describes the guidelines for clarifying abnormal liver values: increased transaminases in relation to alkaline phosphatase indicate damage to the liver cells, and a predominantly increased alkaline phosphatase indicates cholestasis. Increased OLD and AST after a hard session can be explained by this; The same study found no such increase for bilirubin.

• Upwards, indirect share: The gene variant described is documented. Other causes include an increased breakdown of red blood cells as well as fasting and infections; There is no study of this in the works used here.
• Up, direct share: Cholestasis, including oral anabolic androgenic steroids. The swallowed representatives include Stanozolol, Oxymetholone and Superdrol, each with its own source in the article there.
• Not up: an hour of weight lifting, at least in the study mentioned.

What this means in strength training

• A baseline before you start is half the battle. If you know your own total bilirubin is 1.4 mg/dl and know that the direct proportion is 0.2, you don't have to guess at the same value under a course of treatment.
• Without the division, the value cannot be read. If the report only says “total bilirubin”, the information that is important is missing.
• The increasing direct share is the indication, not the total value. It can represent cholestasis or damage to the liver cells and belongs together with Gamma-GT and the alkaline phosphatase read. In the study mentioned, total bilirubin, gamma-GT and alkaline phosphatase remained within the normal range after exercise; the direct share was not specifically shown there.
• Waiting for yellowing means waiting for a full frame. In the series of 44 men, everyone ended up with one, and 71 percent ended up in the hospital. The paper does not report when it occurred.
• Yellow discoloration, dark urine or light-colored stools should be checked by a doctor, and not in the forum. This is the usual rule of caution and not a finding from the work mentioned here.

Classification

Bilirubin is the laboratory value in which the breakdown is more important than the level. A mildly elevated unconjugated proportion fits with a widespread benign predisposition, which is even associated with less vascular damage in population data; Other causes should still be ruled out. An increased conjugated portion, on the other hand, can represent the cholestatic liver damage that occurs when substances are swallowed.

What follows is unspectacular and yet rarely done: allow the direct portion to be determined, have a baseline value, and read bilirubin along with gamma-GT and alkaline phosphatase, which remained unchanged after an hour of weight lifting. Total bilirubin by itself does not answer any of the questions for which it is taken.

The question of the cause behind the population findings remains open. Whether the uncoupled bilirubin actually protects the vessels or whether it is just associated with something else cannot be decided from observational data. There is no study that specifically increases the value and counts events among the works used here.

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