Biliary atresia (BA), a rare but serious liver disease in infants, can progress rapidly from subtle newborn signs to irreversible liver injury. Early treatment with Kasai portoenterostomy (KP) offers the best chance of delaying or avoiding liver transplantation, yet many infants are diagnosed after the optimal treatment window has passed. A newly described clinical strategy aims to shorten this delay by pairing direct or conjugated bilirubin (DB/Bc) measurements with a feeding abdominal ultrasound exam, providing a practical pathway for earlier detection.
Researchers from Texas Children's Hospital and Baylor College of Medicine, in collaboration with Stanford University School of Medicine, published a review in World Journal of Pediatric Surgery (DOI: 10.1136/wjps-2025-001142) detailing the approach. The pathway begins with DB/Bc testing in the newborn nursery and during early outpatient visits. Evidence indicates that DB/Bc levels can be elevated within the first 24–48 hours of life in infants with BA, before clinical signs or other liver injury markers appear. Primary care providers are advised to test DB/Bc at 2–4 weeks for infants with persistent jaundice, pale stools, or a prior elevated result, consistent with American Academy of Pediatrics guidelines.
The second step involves a feeding abdominal ultrasound for infants with high DB/Bc levels. Unlike traditional fasting ultrasounds, the infant feeds before or during imaging, making 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 authors emphasize that the strategy is designed to make early BA evaluation more actionable for the entire care team, from nursery providers and primary care physicians to radiologists, hepatologists, and surgeons. The goal is not to replace specialist judgment but to provide clearer signals when time is critical. By sharing the pathway, the researchers hope other centers will test and adapt the approach in diverse practice settings.
The implications are broad. Universal newborn DB/Bc screening could reduce diagnostic delays and address disparities by identifying risk before visual signs are missed. The feeding ultrasound approach reduces the burden on families by avoiding fasting and potentially decreasing reliance on tests requiring anesthesia or invasive procedures. For infants, earlier detection could lead to faster treatment decisions and a better chance of preserving the native liver. Future studies will need to evaluate implementation, cost-effectiveness, and performance across multiple centers and healthcare systems.
