Biliary atresia (BA), a rare infant liver disease, can lead to irreversible liver injury if not treated within the first 30–45 days of life. A new clinical strategy described by researchers at Texas Children's Hospital and Baylor College of Medicine, published in World Journal of Pediatric Surgery (DOI: 10.1136/wjps-2025-001142), pairs direct or conjugated bilirubin (DB/Bc) measurements with a feeding abdominal ultrasound to accelerate diagnosis and reduce delays.
The pathway begins with DB/Bc testing in newborns and during early outpatient visits. Elevated DB/Bc levels, which can appear within 24–48 hours of birth in infants with BA, prompt a feeding ultrasound exam. Unlike traditional fasting ultrasounds, the infant feeds before or during imaging, making the duct at the hilum easier to visualize. Key ultrasound signs include maximum echogenicity near the right portal vein greater than 4.0 mm or an absent duct at the hilum, which raise concern for BA and may trigger definitive evaluation.
The approach aims to make early BA evaluation more actionable for primary care providers, radiologists, and specialists. By integrating DB/Bc interpretation through BiliScreen.org, the protocol provides clear signals when time is critical. The authors emphasize that universal newborn screening could reduce disparities in diagnosis, as visual signs like jaundice and pale stools may be missed. Additionally, the feeding ultrasound avoids fasting and may reduce the need for invasive procedures or anesthesia.
Early detection is crucial because Kasai portoenterostomy, performed before 30–45 days, offers the best chance of delaying or avoiding liver transplantation. Despite this, many infants are diagnosed after 60 days. The proposed pathway could lead to faster treatment decisions and better preservation of the native liver. Future studies will need to evaluate implementation and cost-effectiveness across multiple centers.
The research was funded by the NIH National Institute of Diabetes and Digestive and Kidney Diseases, the American Association for the Study of Liver Diseases, the American Liver Foundation, and Biliary Atresia Research and Education, Inc. The work also received philanthropic support from families affected by biliary atresia and from Robert and Annie Graham.
