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What's the deal with ... Gilbert's syndrome?

Unconjugated bilirubin deserves its own #tweetorial

🟨Is it bad or...PLOT TWIST...good!?
🟨What to do about it?
🏆The most 🍌🍌trials ever conducted

#livertwitter #meded #MedTwitter

What is Gilbert's?

1⃣Healthy person gets labs. Bili 2.4, >80% indirect
2⃣Student studies all🌙, forgets 2 eat.
In AM,👀slightly 🟨

Turns out:
👉3% of🌎has bili>1.4mg/dL (fig1)

Many things⬆️indirect bili:
👉Only 1⃣ makes bili⬆️w/fasting (Fig2)



Who?1⃣Described c1901. Hilarious paper
(🙏google translate, my🇨🇦franglish education)
Why?2⃣Familial⬇️UDPGT protein
(the thing that 'conjugates' bili)
Why?3⃣Base pair insertion in UGT1A1 promoter
(#TATAbox, the gene that makes UDPGT)

But ...why is Gilbert's even a thing?
Why so common?

let's back up

Where does unconjugated bili come from?

1⃣Rusty🩸cells give up heme
2⃣Heme-oxygenase➡️Biliverdin➡️unconj bili
3⃣Liver takes bili➡️conjugates, dumps in bile
(👍fig from my old pal Sush Jangi)

non-toxic,🚰soluble, 🟩pigment

Unconjugated Bilirubin:
toxic,🚫soluble,🟨pigment, needs energy 2make,
AND needs 2b conjugated 2b excreted

Why bother?
Why does every mammal make bilirubin?
Why is Gilbert's super common?


Could unconjugated bilirubin... good?

The birth of an idea:
In a 100% 🍌🍌 1938 paper:
🤔Hench saw improved RA symptoms after jaundice
💉So he injected ppl w/bili
😢No benefit


Turns out bili IS an antioxidant with immunomodulating properties

⬆️bilirubin levels or Gilbert mutation associated with

🫁⬇️resp disease
♥️⬇️heart disease
🦀⬇️cancer, particularly colon

and lower risks of RA, crohn's, lupus, and MS

Bring on the bili?

Obviously too much bili is no good

1⃣+ immune associations lost when bili⬆️⬆️
2⃣Absent UDPGT? Keyword: Kernicterus.
That's crigler-najjar.
Type 1: Fatal without☀️therapy♾ or liver transplant
Type 2: 🤏UDPGT activity, induced by phenobarb

Many things alter UDPGT activity

💊phenobarb induces
💊rifampin suppresses
🥃🍷induces, surprisingly

And the time has come!
The most🍌🍌🍌trial I have read

To prevent neonatal jaundice...
...🥃🍷was given to⬆️UDPGT activity in
... pregnant women

If you find an isolated,⬆️unconjugated bili,
how do you congratulate the patient on their Gilbert's?

1⃣You could order the gene test
But then you'd have to wear a top hat qTuesday
Dont @ me. I dont make the rules


2⃣you can follow these pathways (Fig1-2)

This concludes a #tweetorial on Gilbert's!

🟨Isolated hi indirect bili
🟨Unconjugated bili is antioxidant
🟨conjugation🔃by fasting, 💊🚬🥃
🟨A little extra bili may be good

Thank you for reading. Hope you enjoyed

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