What is the first sign of elevated conjugated (direct) bilirubin?

• A. Icteric sclera
• B. Jaundice
• C. Acholic stool
• D. Tea-colored urine

Answer: (D)

Direct (conjugated) bilirubin is water-soluble, so when it rises, it is excreted in the urine, giving the urine a dark, tea-colored appearance. Skin and scleral icterus require higher bilirubin levels to become visible, so jaundice tends to appear after the urine has darkened. Acholic stools result from a lack of bile pigments reaching the intestine and usually appear later with ongoing cholestasis. Thus, the earliest sign of elevated direct bilirubin is tea-colored urine.