Bilirubin in urine: what a positive means, causes and what to check next

Conjugated (direct) bilirubin in the urine, which turns it dark amber. Normally negative at any level — bilirubin only appears when the liver has processed it and cannot send it into bile.

Any positive is abnormal and points to the liver or bile ducts: hepatitis, a blocked duct (gallstone, stricture, pancreatic mass), drug-induced liver injury or cirrhosis; it often appears before jaundice and before blood bilirubin is obviously raised.

Full reference table, citations and testing options: Bilirubin in Urine biomarker page.

1. Acute viral hepatitis A, B, C and E, mononucleosis and other viral hepatitides — urine bilirubin often precedes jaundice
2. Alcoholic hepatitis and cirrhosis of any cause
3. Drug- and supplement-induced liver injury — acetaminophen, amoxicillin-clavulanate, isoniazid, anabolic steroids, methotrexate, some herbal and bodybuilding products
4. Bile-duct obstruction — a gallstone in the common duct, a stricture, primary sclerosing cholangitis, a tumor of the pancreatic head, bile duct or ampulla
5. Intrahepatic cholestasis — estrogens and oral contraceptives, anabolic steroids, chlorpromazine, some antibiotics, primary biliary cholangitis, cholestasis of pregnancy, sepsis, parenteral nutrition
6. Autoimmune hepatitis and ischemic hepatitis after shock or heart failure
7. Dubin–Johnson and Rotor syndromes — inherited, benign causes of a raised conjugated bilirubin
8. False positives — phenazopyridine, chlorpromazine metabolites, etodolac and strongly pigmented urine; a positive that cannot be reproduced on a fresh sample with a normal serum direct bilirubin

• Dark, tea- or cola-colored urine, often the first sign; a yellow foam when shaken
• Pale or clay-colored stools and itching when bile flow is blocked
• Yellowing of the whites of the eyes and skin, days after the urine changes
• Fatigue, nausea, loss of appetite and right-upper-abdominal discomfort; fever with hepatitis or cholangitis

• A hepatic function panel the same week: total and direct bilirubin, ALT, AST, alkaline phosphatase, GGT and albumin, with a prothrombin time or INR
• Hepatitis A IgM, hepatitis B surface antigen and core IgM, and hepatitis C antibody when the aminotransferases are raised
• A complete medication, supplement, alcohol and travel history — stop any suspected drug or supplement
• An abdominal ultrasound of the liver and bile ducts promptly when the alkaline phosphatase is raised, the stools are pale or the urine urobilinogen is low; dilated ducts mean obstruction and a specialist referral
• A repeat on a fresh sample kept out of light if the first was old or taken on phenazopyridine or another coloring drug
• Serum bile acids in pregnancy with itching; autoimmune markers and ferritin when the cause remains unexplained

Follow-up tests available at TestWell: Ferritin Test ($21.99), ALT Test (Alanine Aminotransferase) ($16.99), GGT Test (Gamma-Glutamyl Transferase) ($19.99).