A review published in World Journal of Pediatric Surgery describes a practical clinical pathway developed at Texas Children's Hospital and Baylor College of Medicine to accelerate diagnosis of biliary atresia (BA) in infants. The approach pairs direct or conjugated bilirubin (DB/Bc) measurements with a feeding abdominal ultrasound exam, aiming to identify infants needing urgent evaluation within the optimal treatment window.
BA is a rare liver disease in which the bile ducts are absent or blocked, leading to progressive liver injury if untreated. Early Kasai portoenterostomy (KP) before 30–45 days of life offers the best chance of avoiding liver transplantation, yet diagnosis is often delayed beyond 60 days. The disease is difficult to detect because early jaundice can resemble common newborn conditions, and pale stools may not appear immediately.
The pathway begins with DB/Bc testing in the newborn nursery and at early outpatient visits. Evidence suggests that DB/Bc levels can be elevated within 24–48 hours of life in infants with BA, before other clinical signs emerge. Primary care providers are guided to test at 2–4 weeks for infants with persistent jaundice, pale stools, or a previous high result, following American Academy of Pediatrics recommendations.
The second step is a feeding ultrasound exam for infants with elevated DB/Bc levels. Unlike traditional fasting ultrasounds, 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; an MxE greater than 4.0 mm or an absent duct raises concern for BA and may prompt definitive evaluation, while other findings support continued outpatient monitoring.
The authors emphasize that the strategy is designed to make early evaluation actionable for the entire care team, from nursery providers and primary care physicians to radiologists, hepatologists, and surgeons. They note it does not replace specialist judgment but aims to provide clearer signals when time is critical. By sharing the pathway, they hope other centers will test and adapt it to their own workflows.
The potential implications include reduced diagnostic delays, fewer invasive procedures, and decreased disparities in diagnosis. Universal newborn DB/Bc screening could identify risk before visual signs are missed or misread, while feeding ultrasound avoids fasting and may reduce reliance on tests requiring anesthesia. For families, earlier detection could mean faster treatment decisions and better chances of preserving the native liver. Future studies will evaluate implementation, cost-effectiveness, and performance across multiple centers. The work was funded by the NIH, the American Association for the Study of Liver Diseases, the American Liver Foundation, and Biliary Atresia Research and Education, Inc., with philanthropic support from families and Robert and Annie Graham. The review is available at https://doi.org/10.1136/wjps-2025-001142.
