Jonathan Ritter, PharmD, PhD (Pharmacology) | Written by Puya Yazdi, MD | Last updated: April 7, 2021

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Urobilinogen is a byproduct of bilirubin that is eventually eliminated through the stool and urine. Although urobilinogen is normally found in the urine, higher or lower levels may be a sign of a liver problem. Read on to find out what urobilinogen is, how it can be tested, and what its levels may reveal about your health.

What is Urobilinogen?

Urobilinogen is a colorless pigment produced from the breakdown of bilirubin by gut bacteria. The majority of this compound is excreted in feces, and a small amount is reabsorbed and excreted in the urine <1>.

When bilirubin production increases because of red blood cell destruction (hemolysis) or liver disease, urobilinogen levels rise in the urine. On the other hand, when insufficient bilirubin reaches the gut due to decreased bile flow, urobilinogen production is reduced, resulting in extremely low or absent urinary urobilinogen levels. For these reasons, a urobilinogen test is used with other tests to help detect liver, gallbladder, or red blood cell problems <1, 2>.

Urobilinogen Tests

Urobilinogen is most commonly measured in the urine. This is usually done as part of a urinalysis test, which measures many other substances in your urine, including proteins, ketones, and glucose. A urinalysis is often part of a routine health exam to screen for early signs of disease <3>.

Your doctor may also order this test to monitor existing liver conditions, or if you have symptoms of liver disease. These include <4, 5, 6>:

yellowing of the skin and eyes (jaundice)dark-colored urinenausea and vomitingitchy skinchillsfeverloss of appetiteweakness/fatiguedisorientation or confusion

Urobilinogen levels can also be measured in the stool (although this is not done as often).

Normal Levels

Urobilinogen is normally found in trace amounts in the urine (0.2 – 1.0 mg/dL) <7>.

Urobilinogen levels 1.0 mg/dL are considered high <8>.

However, these values vary from lab to lab.

Limitations

One study found that although the urine urobilinogen test was a good screen for elevated blood bilirubin levels, it was not as useful for detecting liver problems due to a high proportion of false-negative results <9>.

The urobilinogen test, by itself, is not enough to diagnose any condition. Talk to your doctor about what your test results mean and how to manage any underlying health conditions <10>.

Low Urobilinogen Levels

Symptoms

Symptoms of low urobilinogen levels depend on the underlying cause. If you have reduced bile flow, you may experience <11, 12>:

Itchy skinFatigueYellow complexion (jaundice)Dark urineLightly colored or foul-smelling stoolAnorexiaNauseaVomitingWeight loss

Causes

1) Reduced Bile Flow

Cholestasis, or reduced bile flow from the liver to the intestines, can cause bilirubin to build up in the bloodstream instead of being eliminated normally. This can reduce the production of urobilinogen, which leads to lower levels in the urine <1, 13>.

Urinary urobilinogen levels were significantly lower in infants with biliary atresia (narrow, blocked, or absent bile ducts) compared to healthy infants in an observational study of 75 infants <13>.

Causes of cholestasis include <12>:

Bile duct blockage (gallstones, cysts, and tumors)Liver disease/damagePregnancySevere infectionPancreatic cancer

Generally, if you have symptoms of liver disease and bilirubin in your urine but an absence of or low urobilinogen, this suggests that not enough bile is flowing to your gut <1, 5>.

2) Certain Medications

Broad-spectrum antibiotics destroy gut bacteria, which can prevent the production of urobilinogen <1>.

In a study of 18 healthy people, antibiotic treatment for 6 days reduced urobilinogen levels in the stool <14>.

False Negative Results

Some factors can interfere with your lab tests and cause false negative results. These include <1, 3, 15, 8>:

Ways to Increase Urobilinogen

1) Treat Underlying Conditions

Address any underlying conditions that are causing low urobilinogen levels.

If you have cholestasis (reduced bile flow), promote the health of your liver by:


2) Review Your Medications

If you are taking antibiotics, discuss lowering your dose or alternative options with your doctor.

High Urobilinogen Levels

Symptoms

Symptoms of high urobilinogen levels in your urine depend on the underlying cause. If you have a liver or gallbladder disease, you may experience <4, 5, 6>:

yellowing of the skin and eyes (jaundice)dark-colored urinenausea and vomitingchillsfeverloss of appetiteweakness/fatiguedisorientation or confusion

If you have hemolysis (red blood destruction), you may have <25>:

dark urineback painyellow skin (jaundice)rapid heart rate (tachycardia)anemia

Causes

1) Liver Disease or Damage

Liver damage and disease (e.g., viral hepatitis and liver cirrhosis) can increase bilirubin levels, resulting in higher urobilinogen levels in the urine <1>.

Urobilinogen levels also correlate with blood levels of liver enzymes (e.g. ALT, AST), which rise in response to liver damage <26>.

2) Excessive Red Blood Cell Breakdown

Conditions that increase the destruction of red blood cells (e.g. hemolytic anemia, pernicious anemia, intravascular hemolysis, congestive heart failure) raise bilirubin levels, which increases the production of urobilinogen in the gut <1, 27, 3>.

Usually, if you have excess red blood cell destruction (hemolysis), you will have urobilinogen in your urine but undetectable amounts of bilirubin <1, 28>.

3) Malaria

Urobilinogen levels were higher in 365 malaria patients <29>.

Another study of 620 people with malaria found that the presence of urobilinogen in the urine was associated with an increased risk of severe malaria with the following complications <30>:

Thrombocytopenia (low platelet count)Neurological dysfunctionLiver dysfunction

False Positive Results

Factors that can lead to false-positive results include <8>:

Elevated nitrate levels in the urineHigh carbohydrate intakeTiming (test is done later in the afternoon)Drugs that make the urine red, such as phenazopyridine (Pyridium)

Ways to Decrease Urobilinogen

1) Treat Underlying Conditions

Address any underlying conditions that are causing low urobilinogen levels. Talk to your doctor about why you may have low urobilinogen and what appropriate therapies are available.

2) Limit Your Alcohol Intake

Drinking too much alcohol can damage liver cells and worsen existing liver conditions <23>.

Alcohol also decreases red blood cells, which may exacerbate anemia. One observational study of 17.7k people found that red blood cell count was reduced by alcohol consumption, with even the lowest intake showing a significant decrease in red blood cells <31>.

3) Review Your Medications

Some drugs or supplements can damage the liver <5, 24>:

Paracetamol (Tylenol)AspirinNon-steroidal anti-inflammatory drugsMethyldopaAmiodaroneMonoamine oxidase inhibitorsPhenothiazines (such as chlorpromazine)Sodium valproateOral contraceptives and hormone replacement therapyChaparral leafEphedraGermanderKavaSennaVitamin A

Have a doctor or pharmacist review your medications to see if any could be harmful to the liver.

4) Improve Sleep Quality

Good sleep is essential for liver health. Short sleep duration and poor sleep quality significantly increased the incidence of non-alcoholic fatty liver disease (NAFLD) in an observational study of 69k people <19>.

5) Drink More Coffee

Drinking moderate to high amounts of coffee (regardless of caffeine content) on a regular basis may benefit liver health. In an observational study of 28k people, drinking more than 3 cups of coffee per day was associated with lower levels of liver enzymes (e.g. ALT, AST, ALP, and GGT) <17>.

6) Exercise

If you have anemia resulting from red blood destruction exercise may help. Moderate physical activity signals the body to produce more red blood cells to increase the oxygen supply to your muscles <33>.

However, avoid more intense and strenuous forms of exercise, as these can damage and destroy red blood cells. This is one of the reasons endurance athletes often have anemia <34>.


Dr. Puya Yazdi is a physician-scientist with 14+ years of experience in clinical medicine, life sciences, biotechnology, and nutraceuticals.

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As a physician-scientist with expertise in genomics, biotechnology, and nutraceuticals, he has made it his mission to bring precision medicine to the bedside and help transform healthcare in the 21st century. He received his undergraduate education at the University of California at Irvine, a Medical Doctorate from the University of Southern California, and was a Resident Physician at Stanford University. He then proceeded to serve as a Clinical Fellow of The California Institute of Regenerative Medicine at The University of California at Irvine, where he conducted research of stem cells, epigenetics, and genomics. He was also a Medical Director for Cyvex Nutrition before serving as president of Systomic Health, a biotechnology consulting agency, where he served as an expert on genomics and other high-throughput technologies. His previous clients include Allergan, Caladrius Biosciences, and Omega Protein. He has a history of peer-reviewed publications, intellectual property discoveries (patents, etc.), clinical trial design, and a thorough knowledge of the regulatory landscape in biotechnology. He is leading our entire scientific and medical team in order to ensure accuracy and scientific validity of our content and products.