A newly described clinical strategy from Texas Children's Hospital and Baylor College of Medicine aims to shorten the diagnostic delay for biliary atresia, a rare but serious infant liver disease. Published in World Journal of Pediatric Surgery (DOI: 10.1136/wjps-2025-001142), the approach pairs direct or conjugated bilirubin (DB/Bc) measurements with a feeding abdominal ultrasound exam to help clinicians identify infants who need urgent evaluation while reducing unnecessary invasive testing.
Biliary atresia is thought to begin before birth, when the extrahepatic bile ducts fail to form properly. After birth, bile accumulates in the liver, driving progressive injury and increasing the likelihood of liver transplantation. Studies show that infants treated with Kasai portoenterostomy before 30–45 days of life have better long-term outcomes, yet diagnosis is often delayed beyond 60 days due to early jaundice resembling common newborn conditions and pale stools that may not appear immediately.
The pathway begins with DB/Bc measurements in the newborn nursery and early outpatient visits. Evidence indicates that DB/Bc levels can be elevated within the first 24–48 hours of life in infants with biliary atresia, before clear clinical signs emerge. Primary care providers are guided to test DB/Bc at 2–4 weeks when infants have persistent jaundice, pale stools, or a previous high result, consistent with American Academy of Pediatrics 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, making the duct at the hilum easier to visualize. The exam measures maximum echogenicity near the right portal vein. In the proposed workflow, an echogenicity greater than 4.0 mm or an absent duct raises concern for biliary atresia and may prompt definitive evaluation, while other findings support continued outpatient assessment.
The authors emphasize that the strategy is designed to make early evaluation more actionable for the full care team, from nursery providers to specialists. They note that universal newborn DB/Bc screening could reduce diagnostic delays and address disparities by identifying risk before visual signs are missed. The feeding ultrasound approach also avoids fasting and may reduce reliance on tests requiring anesthesia or invasive procedures.
Future studies will need to evaluate implementation, cost-effectiveness, and performance across multiple centers. The work was funded by grants from the NIH, the American Association for the Study of Liver Diseases, the American Liver Foundation, and Biliary Atresia Research and Education, Inc., among others.
