Texas Children's Hospital Develops Streamlined Pathway for Earlier Biliary Atresia Diagnosis

A newly described clinical strategy from Texas Children's Hospital and Baylor College of Medicine aims to shorten the diagnostic delay for biliary atresia (BA), a rare but serious infant liver disease. Published in the World Journal of Pediatric Surgery on March 16, 2026, the review outlines a practical pathway that pairs direct or conjugated bilirubin (DB/Bc) measurements with a feeding abdominal ultrasound exam. The approach could help clinicians identify infants needing urgent evaluation while reducing unnecessary invasive testing.

Biliary atresia occurs when the extrahepatic bile ducts do not form properly before birth, leading to bile buildup in the liver and progressive injury. Early treatment with Kasai portoenterostomy (KP) — ideally before 30–45 days of life — offers the best chance of delaying or avoiding liver transplantation. However, diagnosis often occurs beyond 60 days, as early jaundice can resemble common newborn conditions and pale stools may not appear immediately.

The first step in the Texas center's pathway involves DB/Bc testing in the newborn nursery and early outpatient visits. According to the review, DB/Bc levels can be elevated within the first 24–48 hours of life in infants with BA, before clear clinical signs emerge. Primary care providers are guided to repeat testing at 2–4 weeks for infants with persistent jaundice, pale stools, or a previous high DB/Bc result, consistent with American Academy of Pediatrics guidance.

The second step is a feeding abdominal ultrasound exam for infants with high DB/Bc levels. Unlike traditional fasting protocols, 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. 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.

Researchers from Texas Children's Hospital and Baylor College of Medicine, with collaborators from Stanford University School of Medicine, published the review (DOI: 10.1136/wjps-2025-001142). The authors noted 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. They emphasized that the aim is not to replace specialists' judgment but to give clinicians clearer signals when time matters most.

The potential implications are significant. Universal newborn DB/Bc screening could reduce delays and 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 requiring anesthesia or invasive procedures. For families, earlier detection could mean faster treatment decisions and a better chance of preserving the native liver.

Funding for the work came from the NIH National Institute of Diabetes and Digestive and Kidney Diseases (K23DK109207), the American Association for the Study of Liver Diseases, the American Liver Foundation, and Biliary Atresia Research and Education, Inc (BARE), along with philanthropic contributions from families and from Robert and Annie Graham. Future studies will need to evaluate implementation, cost-effectiveness, and performance across multiple centers and healthcare systems.