A newly described clinical strategy from a Texas pediatric center could help clinicians identify biliary atresia (BA) earlier, potentially improving outcomes for infants with this rare but serious liver disease. The approach, detailed in a review published March 16, 2026, 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 exam to shorten the diagnostic delay that often leads to irreversible liver injury.
Biliary atresia occurs when the extrahepatic bile ducts do not form properly, causing bile to build up in the liver. Early treatment with Kasai portoenterostomy (KP) before 30–45 days of life offers the best chance of delaying or avoiding liver transplantation, but many infants are diagnosed after 60 days, when the treatment window has passed. The disease is difficult to detect because early jaundice can resemble common newborn conditions, and pale stools may not appear immediately.
The pathway, developed by researchers from Texas Children's Hospital and Baylor College of Medicine, with collaborators from Stanford University School of Medicine, begins with DB/Bc testing in the newborn nursery and early outpatient visits. Evidence shows that DB/Bc levels can be elevated in the first 24–48 hours of life in infants with BA, before clear clinical signs emerge. Primary care providers are guided to test at 2–4 weeks when infants have persistent jaundice, pale stools, or a previous high DB/Bc result, consistent with American Academy of Pediatrics guidance.
The second step involves 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 may support continued outpatient assessment.
The authors said the strategy is designed to make early BA evaluation more actionable for the full care team, from nursery providers and primary care physicians to radiologists, hepatologists, and surgeons. They emphasized that the aim is not to replace specialists' judgment but to give clinicians clearer signals at the moment when time matters most. By sharing the pathway, they hope other centers will provide feedback, test the approach in different practice settings, and adapt useful parts into their own workflows.
The potential implications are broad. Universal newborn DB/Bc screening could reduce delays and may also help address disparities in diagnosis by identifying risk before visual signs are missed or misread. The feeding ultrasound approach could make follow-up evaluation less burdensome by avoiding fasting and potentially reducing reliance on tests that require anesthesia or invasive procedures. For families, earlier detection could mean 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.
