A new clinical strategy published in the World Journal of Pediatric Surgery offers a practical pathway to speed up diagnosis of biliary atresia (BA), a rare but devastating infant liver disease. The approach, developed at Texas Children's Hospital and Baylor College of Medicine in collaboration with Stanford University School of Medicine, pairs direct or conjugated bilirubin (DB/Bc) testing with a feeding abdominal ultrasound exam. The goal is to identify infants who need urgent evaluation before irreversible liver damage occurs, while reducing unnecessary invasive procedures for those unlikely to have BA.
Biliary atresia is difficult to detect early because initial jaundice can mimic common newborn conditions, and pale stools may not appear immediately. The disease is thought to originate before birth when the extrahepatic bile ducts fail to form properly. After birth, bile accumulates in the liver, causing progressive injury and increasing the likelihood of needing a liver transplant. Studies show that infants treated with Kasai portoenterostomy (KP) before 30–45 days of life have better long-term outcomes, yet diagnosis is often delayed beyond 60 days. The new pathway aims to close this gap by making early evaluation more actionable for the entire care team, from nursery providers and primary care physicians (PCPs) to radiologists, hepatologists, and surgeons.
The first step involves DB/Bc measurements in the newborn nursery and during early outpatient visits. Evidence cited in the review indicates that DB/Bc levels can be elevated within the first 24–48 hours of life in infants with BA, even before clear clinical signs or other liver injury markers emerge. PCPs are guided to test DB/Bc at 2–4 weeks for infants with persistent jaundice, pale stools, or a previous high DB/Bc result, consistent with American Academy of Pediatrics (AAP) guidance. The second step is a feeding abdominal ultrasound exam for infants with high DB/Bc levels. Instead of requiring fasting, the infant feeds before or during imaging, which can make the duct at the hilum (DaH) easier to visualize. The exam also measures maximum echogenicity (MxE) near the right portal vein. In the proposed workflow, an MxE greater than 4.0 mm or an absent DaH raises concern for BA and may prompt definitive evaluation, while other findings support continued outpatient assessment.
The implications of this pathway are significant. Universal newborn DB/Bc screening could reduce diagnostic delays and help address disparities by identifying risk before visual signs are missed or misread. The feeding ultrasound approach makes follow-up evaluation less burdensome by avoiding fasting and potentially reducing reliance on tests requiring anesthesia or invasive procedures. For families, earlier detection could mean faster treatment decisions and a better chance of preserving the native liver. The authors note that the aim is not to replace specialists' judgment but to give clinicians clearer signals when time matters most. They encourage other centers to provide feedback, test the approach in different practice settings, and adapt useful parts into their own workflows.
Future studies will need to evaluate implementation, cost-effectiveness, and performance across multiple centers and healthcare systems. The review 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, among others. The full article is available at https://doi.org/10.1136/wjps-2025-001142.
