Lab result explainedUrinalysisLast updated November 11, 2026

Bilirubin in urine: what a positive, trace or small result on a urinalysis means

Bilirubin in urine · Urinalysis (dipstick) · reported in Reported qualitatively as negative, trace or small (1+), moderate (2+) or large (3+); some labs give approximate mg/dL. Serum bilirubin is reported in mg/dL (1 mg/dL = 17.1 µmol/L)

Bilirubin in urine (bilirubinuria) is a dipstick finding that should always be negative. Bilirubin is the yellow pigment made when old red blood cells are broken down; the liver processes it into a water-soluble (conjugated or direct) form and sends it into the bile and out through the gut. Only this conjugated form can pass through the kidneys, so bilirubin appears in urine when conjugated bilirubin is backing up into the blood, which happens for two reasons: liver cells are injured and leaking it (hepatitis from viruses, alcohol, drugs or fatty liver), or the bile ducts are blocked (gallstones, strictures, tumors of the pancreas or bile duct).

The result is reported as negative, trace or small (1+), moderate (2+) or large (3+). Even a trace result is worth a closer look, because urine bilirubin often turns positive before the skin and eyes look yellow, when blood bilirubin is still only modestly raised. That said, a single trace result in a dark, concentrated sample or in someone taking a urine-coloring drug such as phenazopyridine is frequently a false positive, and a repeat on a fresh sample, with blood tests for total and direct bilirubin, ALT, AST, alkaline phosphatase and GGT, is the usual next step.

Conditions that raise only the unconjugated form of bilirubin, such as Gilbert's syndrome and hemolysis, do not produce bilirubin in urine, because unconjugated bilirubin is bound to albumin and cannot be filtered. This is why the dipstick is useful: a positive urine bilirubin tells you the problem is conjugated and therefore in the liver or bile ducts, and reading it together with urine urobilinogen narrows it further. Bilirubin present with low or absent urobilinogen suggests complete bile duct obstruction; bilirubin present with high urobilinogen suggests liver cell damage.

Bilirubin in urine at a glance

What it is: a dipstick test for conjugated (direct) bilirubin in urine; the pad detects about 0.4 to 0.8 mg/dL and reports negative, trace/small (1+), moderate (2+) or large (3+).
Normal: negative. Healthy urine contains almost no bilirubin (under 0.02 mg/dL).
Positive means conjugated bilirubin is raised in the blood: liver cell injury (viral, alcoholic or drug-induced hepatitis, cirrhosis) or a blocked bile duct (gallstones, pancreatic or bile duct tumors, cholangitis).
Trace results are often false positives from concentrated or pigmented urine or drugs such as phenazopyridine; light exposure, standing and vitamin C cause false negatives. Repeat on a fresh sample and check blood bilirubin and liver enzymes.
It does not detect unconjugated bilirubin, so hemolysis, Gilbert's syndrome and newborn jaundice give a negative urine test.
Next step: serum total and direct bilirubin, ALT, AST, alkaline phosphatase, GGT; an ultrasound of the liver and bile ducts if direct bilirubin or alkaline phosphatase is raised.

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What Bilirubin in urine measures

Bilirubin comes from the heme in red blood cells, which are recycled after about 120 days. The unconjugated bilirubin released travels to the liver bound to albumin, where liver cells attach glucuronic acid to make conjugated bilirubin, which is water-soluble and secreted into bile. In the gut, bacteria convert it to urobilinogen, most of which leaves in stool (as stercobilin, which colors it brown); a little is reabsorbed and excreted in urine. Normally the plasma contains 0.1 to 1.2 mg/dL of total bilirubin, almost all unconjugated, and less than 0.3 mg/dL conjugated, so no measurable bilirubin reaches the urine. When conjugated bilirubin rises in plasma it is filtered freely by the kidneys and appears in urine.

The dipstick pad contains a diazonium salt that couples with conjugated bilirubin in acid conditions to form a tan to purple color read after about 30 seconds; the depth of color gives the 1+ to 3+ grade. Its detection limit of roughly 0.4 to 0.8 mg/dL is coarse, and the color can be masked by very dark urine. A tablet test (Ictotest), which detects 0.05 to 0.1 mg/dL, is used by some labs to confirm a positive or questionable strip. Neither test measures unconjugated bilirubin, which is albumin-bound and not filtered.

The test is fragile. Conjugated bilirubin is oxidized to biliverdin by light and breaks down on standing, so a sample left in daylight or tested hours after collection can read falsely negative; samples should be tested within 2 hours and kept covered. Large amounts of vitamin C and high nitrite concentrations also suppress the reaction. False positives come from drugs that color urine orange-red (phenazopyridine, rifampin), from chlorpromazine metabolites and etodolac, and from very concentrated or pigmented urine. Any unexpected positive is repeated on a fresh, protected sample before conclusions are drawn.

Normal range for Bilirubin in urine

Reference ranges vary between labs and by age, sex and pregnancy. Use the range printed on your own report.

Group	Typical range (Reported qualitatively as negative, trace or small (1+), moderate (2+) or large (3+); some labs give approximate mg/dL. Serum bilirubin is reported in mg/dL (1 mg/dL = 17.1 µmol/L))	Notes
Negative	No color change on the pad (below about 0.4 mg/dL)	The normal result at any age. Healthy urine contains less than 0.02 mg/dL of bilirubin.
Trace or small (1+)	Roughly 0.5–1 mg/dL of conjugated bilirubin in urine	Earliest detectable level; may precede visible jaundice. Also the grade most often produced by false positives (concentrated or pigmented urine, phenazopyridine). Repeat on a fresh sample and check serum direct bilirubin.
Moderate (2+)	Roughly 1–2 mg/dL	Usually accompanies a serum direct bilirubin above 1 mg/dL and dark, tea-colored urine. Liver blood tests and an ultrasound are indicated.
Large (3+)	Above about 2–3 mg/dL	Seen with marked conjugated hyperbilirubinemia from obstruction or severe hepatitis; jaundice is usually visible. Pale stools alongside point to bile duct obstruction.
Serum total bilirubin, normal (for context)	0.1–1.2 mg/dL	Labs differ slightly. Visible jaundice appears above about 2.5 to 3 mg/dL.
Serum direct (conjugated) bilirubin, normal	Below 0.3 mg/dL	Urine bilirubin becomes positive as the direct fraction rises; a direct fraction above about 20 to 30 percent of total is conjugated hyperbilirubinemia.
Urine urobilinogen (companion pad), normal	0.2–1.0 mg/dL (Ehrlich units)	Bilirubin positive with urobilinogen absent suggests complete bile duct obstruction; bilirubin positive with urobilinogen raised suggests liver cell damage; bilirubin negative with urobilinogen raised suggests hemolysis.

Positive bilirubin in urine

A confirmed positive urine bilirubin means the conjugated (direct) fraction of bilirubin in your blood is raised, and that in turn means one of two things: liver cells are damaged enough that conjugated bilirubin leaks back into the blood instead of into bile, or the flow of bile out of the liver is blocked somewhere between the small bile ducts and the duodenum. Because it can be the earliest sign, appearing days before the whites of the eyes turn yellow, a positive result in someone who feels unwell, has dark urine, pale stools, itching, nausea or right upper abdominal pain is treated as a liver problem until proven otherwise.

The pattern of the blood tests then separates the two groups. Hepatocellular injury (viral hepatitis A, B, C or E, alcoholic hepatitis, drug or supplement toxicity, autoimmune hepatitis, ischemic hepatitis, severe fatty liver disease) raises ALT and AST far more than alkaline phosphatase. Cholestasis or obstruction (gallstones in the common bile duct, cholangitis, pancreatic head cancer, bile duct cancer, primary biliary cholangitis, primary sclerosing cholangitis, some drugs such as amoxicillin-clavulanate and anabolic steroids) raises alkaline phosphatase and GGT disproportionately. An ultrasound showing dilated bile ducts confirms obstruction and leads to further imaging and often an endoscopic procedure to relieve it.

Two rare inherited conditions, Dubin-Johnson and Rotor syndromes, cause a mild lifelong conjugated hyperbilirubinemia with a positive urine bilirubin and otherwise normal liver tests; they are harmless. A trace result with completely normal blood bilirubin and liver enzymes is almost always a false positive from concentrated or drug-colored urine and needs no further action beyond a repeat.

Common causes

Viral hepatitis
Hepatitis A, B, C and E and, less often, Epstein-Barr or cytomegalovirus inflame liver cells; dark urine from bilirubin is often the first thing people notice, a few days before jaundice. ALT and AST are typically in the hundreds or thousands.
Gallstones blocking the common bile duct
A stone that migrates out of the gallbladder obstructs bile flow, producing pain, bilirubin in urine, pale stools and a raised alkaline phosphatase; with fever and chills it is cholangitis, an emergency. Gallstones are more common in pregnancy and after rapid weight loss.
Alcohol-related liver disease
Alcoholic hepatitis and cirrhosis impair conjugated bilirubin excretion; a bilirubin above 3 mg/dL with a prolonged prothrombin time marks severe disease. AST is usually about twice ALT.
Drug- and supplement-induced liver injury
Acetaminophen overdose, amoxicillin-clavulanate, isoniazid, nitrofurantoin, anabolic steroids, methotrexate and some herbal and bodybuilding supplements (green tea extract concentrates, kava, high-dose vitamin A) cause hepatitis or cholestasis; bilirubin in urine with a new medication in the past 3 months is a prompt to stop it and test.
Cancers of the pancreas, bile duct or liver
A tumor at the head of the pancreas or in the bile ducts compresses the duct and causes painless progressive jaundice with itching, weight loss and bilirubin in urine, typically in people over 60. Liver metastases and primary liver cancer can do the same.
Cirrhosis of any cause
Scarred liver from alcohol, fatty liver disease, chronic hepatitis B or C or autoimmune disease loses the capacity to excrete bilirubin, so urine bilirubin appears as the disease decompensates, often with low albumin, a raised INR and fluid retention.
Primary biliary cholangitis and primary sclerosing cholangitis
Autoimmune destruction of small bile ducts (mainly women in middle age, with itching and a positive anti-mitochondrial antibody) or inflammatory narrowing of larger ducts (often with ulcerative colitis) cause chronic cholestasis with bilirubin in urine late in the course.
Liver problems of pregnancy
Intrahepatic cholestasis of pregnancy (itching, raised bile acids, usually mild bilirubin rise), acute fatty liver of pregnancy and HELLP syndrome can all produce urine bilirubin in the third trimester, as can gallstones and viral hepatitis; a normal pregnancy does not. Any positive result in pregnancy is evaluated promptly.
Dubin-Johnson and Rotor syndromes
Rare inherited defects in moving conjugated bilirubin into bile; lifelong mild jaundice, positive urine bilirubin, normal liver enzymes and no treatment needed.
False positive
Phenazopyridine (urinary analgesic), rifampin, chlorpromazine, etodolac and very dark, concentrated urine can mimic a positive pad, usually at the trace level. Serum bilirubin and a repeat on a fresh sample settle it.

Symptoms that can go with it

Dark, tea- or cola-colored urine that foams yellow when shaken
Yellowing of the whites of the eyes and skin (jaundice), which may appear days after the urine changes
Pale, clay-colored or greasy stools, which point to bile duct obstruction
Itching without a rash, often worst on the palms and soles and at night
Nausea, loss of appetite, fatigue and aching in the right upper abdomen
Fever and chills with abdominal pain, suggesting cholangitis or hepatitis
Unexplained weight loss with painless jaundice, which needs urgent investigation for cancer
Often no symptoms at a trace level, particularly when the result is a false positive

Read it alongside

Bilirubin (total serum) and direct bilirubin — confirm the finding and show how much of the rise is conjugated; a normal direct bilirubin with a positive urine test means a false positive.
Urobilinogen in urine — absent with complete bile duct obstruction, raised with liver cell damage or hemolysis; the two pads together point toward the cause.
ALT and AST — raised far more than alkaline phosphatase in hepatitis; AST about twice ALT suggests alcohol.
Alkaline phosphatase and GGT — raised disproportionately in cholestasis and bile duct obstruction; GGT confirms the alkaline phosphatase is from the liver rather than bone.
Albumin and PT/INR — measure the liver's synthetic function; a low albumin or high INR indicates severe or chronic liver disease.
Hepatitis B surface antigen and hepatitis C antibody — the first viral tests in anyone with a new conjugated hyperbilirubinemia.
Lipase — raised when a stone or tumor also obstructs the pancreatic duct.
Haptoglobin and LDH — check for hemolysis when blood bilirubin is high but urine bilirubin is negative (unconjugated pattern).

What usually happens next

A trace or unexpected positive is repeated on a fresh midstream sample kept out of light and tested within 2 hours, after noting any urine-coloring medications; if the repeat is negative and you feel well, nothing more is needed.
A confirmed positive is followed by blood tests for total and direct bilirubin, ALT, AST, alkaline phosphatase, GGT, albumin and INR, and often a complete blood count.
If direct bilirubin or alkaline phosphatase is raised, an ultrasound of the liver, gallbladder and bile ducts is the first imaging test: dilated ducts mean obstruction and lead to MRCP or endoscopic ultrasound and usually an ERCP to remove a stone or place a stent.
If the pattern is hepatocellular, expect hepatitis A, B and C serology, questions about alcohol, acetaminophen and every medication and supplement taken in the past 3 months, and sometimes autoimmune antibodies, ferritin and ceruloplasmin.
In pregnancy, a positive urine bilirubin prompts same-week liver tests and serum bile acids to look for intrahepatic cholestasis, HELLP or acute fatty liver, and an ultrasound for gallstones.
Stop alcohol and any non-essential supplement until the cause is known; do not start anything new to 'support the liver' while tests are pending.

Diet, lifestyle and natural levers with evidence

What can move Bilirubin in urine once the cause is known. Nothing here replaces finding the cause.

Stopping alcohol

Strong evidence

No dietary or herbal measure clears bilirubin from urine; the result changes when the liver or bile duct problem resolves. For alcohol-related liver disease, abstinence is the single intervention with the largest effect: in alcoholic hepatitis bilirubin typically starts falling within 1 to 2 weeks of stopping, and in alcohol-related cirrhosis five-year survival is roughly 60 percent in people who stop drinking versus around 35 percent in those who continue. Even in liver disease from other causes, alcohol accelerates damage and is stopped completely until the liver tests normalize.

Reviewing medications and supplements that injure the liver or distort the test

Moderate evidence

Herbal and dietary supplements now account for about 20 percent of drug-induced liver injury cases in the US Drug-Induced Liver Injury Network, led by bodybuilding products, green tea extract concentrates, kava and multi-ingredient weight-loss blends; stopping the product is the treatment and most people recover over weeks. Separately, phenazopyridine and rifampin color urine and cause false-positive bilirubin pads, while more than 1 g a day of vitamin C can cause false negatives. Bring a full list of everything you take, including supplements, to the appointment.

Do not add 'liver support' products while a positive bilirubin is being investigated; several have themselves caused liver injury.

Coffee

Moderate evidence

In large cohort studies, regular coffee drinkers have lower ALT, GGT and bilirubin and lower rates of cirrhosis and liver cancer; a 2016 meta-analysis of 9 studies found that each extra 2 cups a day was associated with a 44 percent lower risk of cirrhosis, with similar protection across alcohol-related, viral and fatty liver disease. The evidence is observational and coffee does not treat an acute hepatitis or an obstructed duct, but there is no reason to stop it in chronic liver disease and some reason to continue.

Milk thistle (silymarin)

Preliminary evidence

Silymarin is widely used for liver disease, but randomized trials are disappointing: a 2017 meta-analysis found statistically significant but clinically trivial reductions in ALT and AST (under 1 IU/L on average), and trials in hepatitis C and alcoholic liver disease showed no effect on bilirubin, viral load or survival. It is safe at 140 to 420 mg a day of standardized extract, but it does not substitute for finding and treating the cause of bilirubin in urine.

Can interact with drugs metabolized by CYP2C9 and may lower blood glucose slightly; allergy in people sensitive to ragweed.

When to see a clinician promptly

Bilirubin in urine with fever, chills and right upper abdominal pain: possible cholangitis (infected, blocked bile duct), an emergency that needs same-day hospital assessment.
Jaundice with confusion, drowsiness, easy bruising or vomiting blood: possible acute liver failure or decompensated cirrhosis; call emergency services.
Any positive urine bilirubin in pregnancy, particularly with itching, nausea, upper abdominal pain or headache, which needs same-week evaluation for cholestasis, HELLP or acute fatty liver.
Painless, progressive jaundice with itching and weight loss, especially over 60, which needs urgent imaging for pancreatic or bile duct cancer.
A positive result after acetaminophen overdose or a new medication or supplement started in the past 3 months.
A confirmed positive result at any level, even without symptoms, which should be followed up with liver blood tests within days rather than weeks.

Frequently asked questions

What does bilirubin in urine mean?

It means conjugated (direct) bilirubin, the water-soluble form processed by the liver, is raised in your blood and spilling into the urine. Healthy urine has none. The two causes are injury to liver cells (viral, alcoholic or drug-induced hepatitis, cirrhosis) and blockage of the bile ducts (gallstones, strictures, pancreatic or bile duct tumors). It often shows up before the skin turns yellow, so a confirmed positive is followed up with blood tests for bilirubin and liver enzymes.

Is trace bilirubin in urine bad?

A trace result is the lowest detectable level and is the grade most often caused by false positives: concentrated dark urine, phenazopyridine (the orange urinary pain reliever), rifampin and some other drugs. It is also, though, the earliest sign of a genuine liver or bile duct problem. The sensible response is to repeat the test on a fresh sample and check serum total and direct bilirubin with ALT, AST and alkaline phosphatase. If those are normal, the trace result was a false positive.

What is the normal range for bilirubin in urine?

Negative. Urine normally contains less than 0.02 mg/dL of bilirubin, far below what a dipstick can detect (about 0.4 to 0.8 mg/dL). Any reported level, from trace to 3+, is abnormal and should be explained, although a single trace in an otherwise healthy person is often a false positive.

What causes bilirubin in urine during pregnancy?

Normal pregnancy does not put bilirubin in urine, so a positive result is evaluated. The pregnancy-specific causes are intrahepatic cholestasis of pregnancy (intense itching, raised bile acids, usually in the third trimester), HELLP syndrome (a severe form of preeclampsia with high blood pressure, abdominal pain and low platelets) and acute fatty liver of pregnancy, all of which need prompt care. Gallstones are more common in pregnancy, and viral hepatitis can occur at any time. Tell your obstetric provider the same day.

Can dehydration cause bilirubin in urine?

Not real bilirubin, but very concentrated, dark urine can produce a false trace reading by masking the pad's color, and it makes any true bilirubin present easier to detect. Dehydration does not raise blood bilirubin in a healthy liver. If you were dehydrated when tested, repeat the test well hydrated; a persistent positive is investigated regardless.

Why is urine bilirubin negative in Gilbert's syndrome and hemolysis?

Because those conditions raise unconjugated bilirubin, which travels bound to albumin and cannot pass through the kidney's filter. Only conjugated bilirubin, made by the liver, is water-soluble enough to appear in urine. So a high blood bilirubin with a negative urine test points to Gilbert's syndrome, hemolysis or newborn jaundice, while a positive urine test points to the liver or bile ducts. Urobilinogen, by contrast, is often raised in urine during hemolysis.

What medications cause a false positive bilirubin in urine?

Phenazopyridine (Pyridium, AZO), which turns urine orange, is the most common; rifampin, chlorpromazine and etodolac metabolites can also react with or discolor the pad. Large doses of vitamin C and high urine nitrite from infection do the opposite and cause false negatives, as does leaving the sample in light or testing it hours after collection. Tell the lab about any of these and repeat the test if the result does not fit.

How is bilirubin in urine treated?

By treating the cause; there is no treatment for the urine finding itself. Gallstones in the bile duct are removed endoscopically, viral hepatitis is managed or treated with antivirals, offending drugs, supplements and alcohol are stopped, autoimmune and cholestatic diseases have specific medications, and tumors are staged and treated. Once bile flow or liver function recovers, blood bilirubin falls over days to weeks and the urine test turns negative.

References

Bilirubin in urine. MedlinePlus, US National Library of Medicine (2023)View source
Bilirubin blood test. MedlinePlus, US National Library of Medicine (2023)View source
Bilirubin test. Mayo Clinic (2024)View source
Simerville JA, Maxted WC, Pahira JJ. Urinalysis: a comprehensive review. American Family Physician (2005)
Roche SP, Kobos R. Jaundice in the adult patient. American Family Physician (2004)
Jaundice. Merck Manual Professional Version (2024)
Fevery J. Bilirubin in clinical practice: a review. Liver International (2008)
Williamson C, Geenes V. Intrahepatic cholestasis of pregnancy. Obstetrics and Gynecology (2014)
Navarro VJ, Barnhart H, Bonkovsky HL, et al.. Liver injury from herbals and dietary supplements in the US Drug-Induced Liver Injury Network. Hepatology (2014)
Kennedy OJ, Roderick P, Buchanan R, et al.. Systematic review with meta-analysis: coffee consumption and the risk of cirrhosis. Alimentary Pharmacology and Therapeutics (2016)
de Avelar CR, Pereira EM, de Farias Costa PR, et al.. Effect of silymarin on biochemical indicators in patients with liver disease: systematic review with meta-analysis. World Journal of Gastroenterology (2017)
Kwo PY, Cohen SM, Lim JK. ACG clinical guideline: evaluation of abnormal liver chemistries. American Journal of Gastroenterology (2017)

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This page is educational and is not medical advice or a diagnosis. Lab results have to be interpreted together with your history, symptoms and other results by a clinician who knows you. Do not start or stop a supplement to change a lab value before the cause is known.