INTRODUCTIONBiliary atresia (BA) is a progressive, idiopathic, fibro-obliterative disease of the

extrahepatic biliary tree that presents with biliary obstruction exclusively in the neonatal
period. Although the overall incidence is low (about one in 10,000 to 20,000 live births, BA is
the most common cause of neonatal jaundice for which surgery is indicated and the most
common indication for liver transplantation in children.

TYPES OF BILIARY ATRESIAInfants with BA can be grouped into three categories:

●Biliary atresia without any other anomalies or malformations – This pattern is sometimes
referred to as perinatal BA, and occurs in 70 to 85 percent of infants with BA. Typically, these
children are born without jaundice, but within the first two months of life, jaundice develops
and stools become progressively acholic.

●Biliary atresia in association with laterality malformations – This pattern is also known as
Biliary Atresia Splenic Malformation (BASM) or "embryonal" biliary atresia, and occurs 10 to 15
percent of infants with BA. The laterality malformations include situs inversus, asplenia or
polysplenia, malrotation, interrupted inferior vena cava, and cardiac anomalies. Data suggest
that children with BASM have poorer outcomes compared with those with perinatal BA,
possibly due to the associated cardiac abnormalities.

●Biliary atresia in association with other congenital malformations – This occurs in the
remaining 5 to 10 percent of BA cases; associated congenital malformations include intestinal
atresia, imperforate anus, kidney anomalies, and/or heart malformations.

Regardless of the type of BA, in each case, the histology and cholangiogram are characteristic:
the histology typically shows inflammation, portal tract fibrosis, cholestasis, and bile duct
proliferation; the cholangiogram demonstrates loss of patency of the extrahepatic bile ducts.

Because of the cholangiographic findings, BA was previously termed "extrahepatic biliary

atresia," to distinguish it from "intrahepatic biliary atresia," which was a histopathologic
grouping of disorders in which the intrahepatic bile ducts are primarily affected. However,
disorders primarily affecting the intrahepatic bile ducts are now categorized by the genetic,
metabolic or infectious cause, rather than by the histologic finding.

PATHOGENESISThe cause of BA is unknown, although several mechanisms have been

implicated, as outlined below. In some patients, several of these mechanisms may contribute
to the development of BA. Conversely, BA may be the common phenotype that can be caused
by a variety of injuries to the biliary system occurring in the perinatal period.

Viral etiologies — Clustering of cases of BA in time and space suggest a possible viral etiology.
As an example, an analysis of 249 cases of BA over a 16-year period in New York State
demonstrated seasonal patterns of incidence that varied by region in the state; in New York
City, the risk of BA was highest for infants born during the Spring months, whereas outside of
New York City infants born in the Fall months had a higher risk. To date, a specific virus has not
been implicated; investigations have failed to identify associations with several specific viral
infections including cytomegalovirus, reovirus, and group C rotavirus. However, one study
reported that infants positive for cytomegalovirus (CMV) immunoglobulin M (IgM) have
reduced clearance of jaundice following Kasai hepatoportoenterostomy (HPE), suggesting that
such infants are a distinct prognostic subgroup.

Toxic etiologies — The clustering of cases of BA is also consistent with the possibility of a toxin-
mediated inflammatory response. The strongest evidence for this hypothesis comes from
three reported outbreaks of BA in lambs in Australia in 1964, 1988, and 2007. In each
outbreak, in a time of drought ewes that gave birth to affected lambs had grazed on lands that
had previously been flooded. A significant number of offspring were thin, jaundiced, had
acholic stools, and eventually died, and autopsy revealed a diagnosis of BA. The hypothesized
mechanism is that the pregnant ewes ingested a toxin when grazing on lands previously
submerged. A novel isoflavonoid toxin was isolated from the Dysphania plant, which was
harvested in Australia at the site of a recent outbreak. This toxin caused severe damage to the
extrahepatic biliary tree in a zebrafish model, and also loss of cilia in neonatal mouse
cholangiocytes. This evidence suggests that an environmental toxin may be implicated in some
cases of BA.

Genetic etiologies — Genetic factors may play a causative role in the small subgroup of
patients with BASM malformations, as suggested by the following observations:

●Mutations in the CFC1 gene, which encodes cryptic protein and is involved in determining
laterality during fetal development, have been associated with BASM syndrome. A
heterozygous mutation in CFC1 was found in five out of ten infants with BASM [23]. The
frequency of this mutation in infants with BASM is twice that found in a population of healthy
individuals. Thus, CFC1 mutations may predispose to BASM but are not sufficient to cause the
disease.

●A transgenic mouse with a recessive deletion of the inversin gene provides an animal model
for BASM, displaying situs inversus and extrahepatic biliary obstruction [24].

●A heterozygous deletion of FOXA2 has been reported in a family with heterotaxy,

panhypopituitarism, and biliary atresia [25].

●With advances in next-generation sequencing technology, additional candidate genes may be

identified in this patient population.

Other than these subgroups of patients with BASM, genetic factors may not play a direct
causative role in the development of most cases of BA; this is suggested by the observation
that monozygotic twins usually have a discordant phenotype. Nonetheless, genetics may still
play a role in disease susceptibility. Association studies have identified a few genomic loci with
increased susceptibility to BA [26-28]. In addition, mutations in the human Jagged1 gene,
which are responsible for Alagille syndrome, have been found in a few cases of biliary atresia
[29]. The Jagged1 gene encodes a ligand in the Notch signaling pathway, which is critical in the
determination of cell fate during development and may also alter production of inflammatory
cytokines. Epigenetic factors have also been postulated as important factors impacting biliary
development and the pathogenesis of BA. Both microRNA and DNA methylation have been
studied in animal models and humans [30,31].

Immunologic etiologies — Immune dysregulation, either as a primary disorder or as the result

of infectious or genetic triggers, has been implicated in various studies.

●A high concentration of maternal chimeric cells has been found in the portal and sinusoidal
areas of patients with biliary atresia, suggesting that maternal lymphocytes cause bile duct
injury through a graft-versus-host immune response [32].

●Coordinated activation of genes involved with lymphocyte differentiation, particularly those

associated with T helper 1 immunity, has been identified in liver samples from infants with
biliary atresia [33].
●Polymorphisms that enhance expression of the CD14 gene, which plays a role in the
recognition of bacterial endotoxin, have been associated with biliary atresia and idiopathic
neonatal cholestasis [34].

CLINICAL FEATURESMost infants with BA are born at full term, have a normal birth weight and
initially thrive and seem healthy.

Signs and symptoms

●Jaundice is the first sign of BA. Initially, the jaundice may be seen only in the sclerae. The
onset of jaundice occurs any time from birth up to eight weeks of age, and it is highly unlikely
to appear later.

●Some infants have acholic stools. Acholic stools often go unrecognized because the stools are
pale but not white and the stool color can vary on a daily basis. To help parents distinguish
between normal and acholic stools, printed "stool color cards," webpages, and a free
smartphone application (PoopMD for iPhone or Android), have been developed [35,36]. In a
study from Japan that included more than 300,000 newborn infants, stool color cards
completed by the parents had a sensitivity of 76.5 percent and specificity of 99.9 percent,
respectively, for identifying infants with biliary atresia [37].

●Most infants have dark urine because of bilirubin excretion into the urine. This often is not
recognized by parents, who may not realize that infant urine should not stain a diaper yellow.

●If the jaundice has gone unnoticed and the child's disease has progressed, there may be a
firm, enlarged liver and splenomegaly.

Laboratory studies — When laboratory studies are performed in infants after they come to
attention because of one of the above symptoms, they reveal elevations in direct and/or
conjugated bilirubin and mild or moderate elevations in serum aminotransferases, with a
disproportionately increased GGTP. If coagulopathy is present at diagnosis, it is most likely due
to vitamin K deficiency.

If laboratory studies are performed shortly after birth (before the infant becomes
symptomatic), mild elevations of conjugated bilirubin are seen. As an example, one study
reported mild elevations in conjugated bilirubin (>0.3 mg/dL) or direct bilirubin (>0.5 mg/dL) at
24 to 48 hours of life in each of 34 infants who were later diagnosed with BA [38]. The mean
serum direct bilirubin level was 1.4 ± 0.43 mg/dL, as compared with 0.19 ± 0.075 in control
infants. The total bilirubin was not elevated at that time and conjugated bilirubin did not
exceed 20 percent of the total bilirubin level.

These observations suggest that infants with mildly elevated conjugated or direct bilirubin
levels in the perinatal period should be followed closely and evaluated for the possibility of BA.
Furthermore, they raise the possibility that measurements of conjugated or direct bilirubin
during the first few days of life could be used as a screening tool for BA [39]. In a pilot study of
such an approach, 11,636 infants were screened for persistent elevations in conjugated or
direct bilirubin during the birth hospitalization, resulting in early identification of two infants
with biliary atresia, and one with alpha-1 antitrypsin deficiency [40]. Further studies are
needed to determine the sensitivity and cost-effectiveness of this measure and its potential
effect on patient outcome.
EVALUATIONInfants with suspected BA should be evaluated as rapidly as possible because the
success of the surgical intervention (hepatoportoenterostomy, the Kasai procedure)
diminishes progressively with older age at surgery [41]. (See 'Predictors of the need for
transplantation' below.)

The evaluation process involves a series of serologic, laboratory, urine, and imaging tests. The
order of diagnostic tests is prioritized based on testing for treatable diseases first, such as
biliary obstruction, infections, and some metabolic diseases. Because the timing of surgery is
crucial for infants with BA, the evaluation should be completed as quickly as possible, and it is
sometimes appropriate to proceed with surgical exploration, even if all of the test results have
not returned. In our practice, we typically proceed with each of the steps below if the infant is
less than six weeks of age. For those patients six weeks and older, we still try to complete a full
evaluation as rapidly as possible (eg, three to four days). Our rationale is that some diseases,
such as Alagille Syndrome or alpha-1-antitrypsin deficiency, can mimic many of the findings of
BA.

Laboratory testing — Evaluation of a young infant with cholestasis includes blood tests to
assess hepatic function and rule out metabolic disease and other etiologies (table 1). Further
detail about the laboratory evaluation of an infant with cholestasis is given in a separate topic
review. (See "Approach to evaluation of cholestasis in neonates and young infants", section on
'Laboratory studies'.)

Abdominal ultrasound — Evaluation of biliary anatomy begins with an ultrasound. The main
utility of the ultrasound is to exclude other anatomic causes of cholestasis (ie, choledochal
cyst) (see "Causes of cholestasis in neonates and young infants", section on 'Biliary cysts'). In
infants with BA, the gallbladder is usually either absent or irregular in shape. When a detailed
ultrasonographic protocol is used, additional features can be identified to support the
diagnosis of biliary atresia, including abnormal gallbladder size and shape, the "triangular cord"
sign, gallbladder contractility, and absence of the common bile duct [42-46]. The triangular
cord sign is a triangular echogenic density seen just above the porta hepatis on US scan. Its
presence is highly suggestive of biliary atresia [47].

Hepatobiliary scintigraphy — Patency of the extrahepatic biliary tree can be further assessed
by hepatobiliary scintigraphy. Although some centers may use phenobarbital to enhance
radioisotope excretion, we do not use phenobarbital because it will delay diagnosis and does
not obviate the need for liver biopsy. Failure of tracer excretion suggests BA, but does not
exclude other diseases. If there is strong suspicion for BA, such as in a patient with acholic
stools, excretion of tracer is unlikely to occur and it is acceptable to proceed directly to liver
biopsy.

Conversely, if scintigraphy demonstrates definite excretion of the tracer from the liver to the
small bowel, patency is established, and BA is very unlikely. In this case, an intraoperative
cholangiogram is not necessary. However, if excretion is noted on a scan that is performed
when the infant is very young (ie, less than six weeks old), and cholestasis persists, the scan
should be repeated one to two weeks later because the disease process may progress during
the neonatal period.

Liver biopsy — We perform a liver biopsy in virtually all infants with suspected biliary atresia
for two reasons. One purpose is to identify histologic changes consistent with obstruction that
warrant surgical exploration. The other is to differentiate BA from other causes of intrahepatic
cholestasis, which would not need surgical exploration.
Biopsy findings that indicate another etiology include bile duct paucity (Alagille syndrome), PAS
positive diastase resistant granules (consistent with alpha-one antitrypsin deficiency), loss of
MDR3 staining (suggestive of PFIC3), or giant cell hepatitis without proliferation of ducts.
Characteristic histologic features of BA include expanded portal tracts with bile duct
proliferation, portal tract edema, fibrosis and inflammation, and canalicular and bile duct bile
plugs. The earliest histological changes associated with BA may be relatively nonspecific, and
biopsies done too early may result in a false negative [48]. At times it is necessary to repeat a
liver biopsy at an older age (eg, two to three weeks later).

Histologic findings alone cannot help to distinguish BA from other causes of obstruction, such
as choledochal cyst or external compression. Therefore, any evidence of obstruction mandates
imaging studies (ie, ultrasonography, if not already done), and a definitive cholangiogram.

Cholangiogram — If the above steps in the evaluation support the diagnosis of BA, the infant
should be taken to the operating room. The first step is an intraoperative cholangiogram,
which is the gold standard in the diagnosis of BA. It is essential that patency be investigated
both proximally into the liver and distally into the bowel to determine whether BA is present. If
the intraoperative cholangiogram demonstrates biliary obstruction (ie, if the contrast does not
fill the biliary tree or reach the intestine), the surgeon should perform a
hepatoportoenterostomy (Kasai HPE) at that time. In some cases, the cholangiogram cannot
be performed because the gallbladder and biliary tree are atretic; in this case the surgeon
makes the diagnostic decision based on visual inspection of the biliary tree.

An alternative yet valid approach used at some centers is to perform a percutaneous

gallbladder cholangiogram or an ERCP [49-51]. These procedures are less invasive than
intraoperative cholangiogram, but performance of these procedures in infants requires special
expertise and equipment. Moreover, if BA is confirmed, the infant will still need to undergo an
operation for treatment. The percutaneous gallbladder cholangiogram can only be performed
in an infant with an identified gallbladder; the procedure is performed by an interventional
radiologist. Alternatively, an endoscopic retrograde cholangiopancreatography (ERCP) can be
used to demonstrate biliary patency in an infant.

DIAGNOSISThe possibility of BA is suggested by the clinical presentation of neonatal

conjugated hyperbilirubinemia and/or acholic stools. The suspicion of BA is strengthened by
results of a variety of tests (typically ultrasound, hepatobiliary scan, and liver biopsy). The
definitive diagnosis is made by intraoperative cholangiogram.

Differential diagnosis — In term infants, biliary atresia and neonatal hepatitis account for a
majority of cases of neonatal cholestasis (table 2). A variety of genetic disorders account for
most of the remainder. In premature infants, cholestasis more often results from total
parenteral nutrition (TPN) or sepsis. The range of causes and an approach to distinguishing
among them are discussed separately.

KASAI PROCEDUREIf BA is confirmed by cholangiogram, a Kasai procedure

(hepatoportoenterostomy [HPE]) should be performed promptly. This operation is undertaken
in the attempt to restore bile flow from the liver to the proximal small bowel (figure 1) [52].
For this procedure, a roux-en-Y loop of bowel is created by the surgeon and directly
anastomosed to the hilum of the liver, following excision of the biliary remnant and portal
fibrous plate.
If the HPE is successful, the remaining small patent bile ducts will drain into the roux limb and
jaundice will start to resolve in the weeks following surgery. Even if bile flow is established and
cholestasis improves, many patients will have slowly progressive liver disease despite
undergoing the Kasai HPE procedure, and the majority of patients with BA will ultimately
require liver transplantation. At least 50 percent of patients who undergo HPE will require liver
transplantation by two years of age as a result of primary failure of the HPE and/or growth
failure. The patient's age at the time of HPE can predict native liver survival at later time
points. As an example, among those patients who undergo HPE ≤30 days of life, the chance of
native liver survival at four years of age is nearly 50 percent, whereas among those who
underwent HPE between 31 and 90 days of life, the chance of native liver survival at four years
of age is 36 percent.

If the HPE is unsuccessful, bile drainage is not achieved, and the child remains jaundiced. If
there is persistent jaundice or elevated serum bilirubin three months after the procedure, the
patient should be referred for liver transplant evaluation.

Revision of a non-functioning HPE generally is not recommended. This is because a revisional

procedure is unlikely to be effective if the original HPE did not achieve bile drainage, and
because the revisional procedure is likely to cause adhesions that increase the technical
difficulty of a subsequent transplant procedure [54]. However, in patients in whom the initial
HPE was successful, revisional HPE may be appropriate if the patient abruptly develops
jaundice, or experiences recurrent episodes of cholangitis but has no other evidence of chronic
liver disease. In one report of 24 patients who underwent revisional HPE for these indications,
75 percent achieved bile drainage and 46 percent survived with their native liver (mean follow-
up 92 months) [55].

Thus, the vast majority of individuals with BA will eventually require liver transplantation.
Nonetheless, the Kasai HPE obviates the need for liver transplantation in a substantial minority
and significantly delays the liver transplantation for many others. If bile drainage is achieved, it
is likely that transplantation will not be needed for years or decades. Patients who undergo
HPE have survival rates with native liver of 35 to 50 percent at four years of age; this compares
favorably with historical series from before the Kasai procedure was introduced in 1968, which
reported a 10 percent survival rate at age three years of age [56,57]. (See 'Liver
transplantation' below.)

Pre-emptive transplant (ie, transplant without prior HPE) is avoided because of the advantages
of transplanting older, larger patients and because of the potential for improved
transplantation therapies in the future. At one time pre-emptive transplantation was used to
avoid the difficulties of performing surgery on a patient with a prior HPE. With modern
transplantation techniques, there is no surgical advantage to pre-emptive transplantation.
Therefore, HPE is almost always performed first.

POSTOPERATIVE MANAGEMENTMedical care following Kasai hepatoportoenterostomy (HPE)

consists of the following interventions, as detailed below [58]:

●Choleretics

●Nutritional supplementation

●Fat-soluble vitamin supplementation

●Prevention of cholangitis
●Management of portal hypertension and its sequelae

Clinical evidence does not support routine use of glucocorticoids in the treatment of BA. (See
'Glucocorticoids (unproven benefit)' below.)

Choleretics — We suggest treating patients with ursodeoxycholic acid (UDCA) after Kasai
hepatoportoenterostomy. This is standard practice in BA, although its clinical utility has not
been definitively established. UDCA is a hydrophilic bile acid; when given by mouth it shifts the
balance of bile acids towards hydrophilic forms. This is thought to stabilize membranes and the
reduce generation of free radicals, thus protecting mitochondria from damage.

The recommended dose of UDCA in BA ranges from 15 to 30 mg/kg/day, and should not
exceed 30 mg/kg/day. To avoid potential toxicity, UDCA therapy should be discontinued if the
total bilirubin level rises above 15 mg/dL (257 micromol/L).

The most convincing human data regarding benefits of UDCA come from the group of patients
with primary biliary cholangitis (PBC). In several large randomized double blind placebo-
controlled trials in patients with PBC, UDCA decreased plasma levels of aminotransferases,
improved liver histology and quality of life, and decreased risk of death and need for liver
transplantation (see "Trials of ursodeoxycholic acid for the treatment of primary biliary
cholangitis (primary biliary cirrhosis)"). However, in patients with primary sclerosing cholangitis
(PSC) a randomized trial suggested negative effects of long-term, high-dose UDCA therapy
[59].

In BA, observational studies suggest a number of possible benefits of UDCA treatment, ranging
from enhanced weight gain to reduced episodes of cholangitis and improved bile flow, but
definitive evidence from randomized trials is lacking [60,61].

Glucocorticoids (unproven benefit) — Clinical evidence does not support routine use of
glucocorticoids in the treatment of BA [62,63]. This was shown in a randomized placebo-
controlled trial of glucocorticoid treatment in 140 infants with BA [64]. The glucocorticoids
were given for 13 weeks (intravenous methylprednisolone 4 mg/kg/day for 2 weeks, followed
by oral prednisolone 2 mg/kg/day for two weeks, then tapering), and outcomes were
measured at 6 and 24 months post HPE. No statistically significant benefit in bile drainage at
six months post HPE was observed in the infants treated with glucocorticoids as compared
with the placebo group. In addition, no statistically significant improvement in survival with
native liver at two years of age was observed in the treatment group. Moreover, the infants
treated with glucocorticoids had significantly earlier onset of serious adverse events as
compared with those given placebo.

Nutrition — Nutritional problems in BA are common and difficult to overcome. Poor nutrition
is a significant clinical problem and is one of the most common indications for liver
transplantation.

Caloric needs — Several factors contribute to malnutrition in patients with BA, including
malabsorption due to cholestasis, chronic liver inflammation, and lack of gall bladder. Because
of malabsorption and metabolic alterations, the total caloric needs in infants with BA are
approximately 150 percent of the recommended energy intake for healthy infants and children
(see "Poor weight gain in children younger than two years: Management", section on 'Energy
requirements for catch-up growth'). To compensate for losses and catabolism, the expected
protein needs are 3 to 4 g/kg/day in infants and 2 to 3 g/kg/day in children [65-67].
In order to meet these nutritional requirements, several strategies are utilized. These
strategies are similar to those used for infants with other causes of growth failure, except that
they should be implemented proactively because of the high rates of growth failure in patients
with BA. (See "Poor weight gain in children younger than two years: Management", section on
'Energy requirements for catch-up growth'.)

●For infants, formulas are concentrated or expressed breast milk is fortified to provide
additional energy. After Kasai HPE, the feed is typically designed to provide 24 kcal per ounce.
If growth is inadequate, the feed may be increased to 27 kcal per ounce; additional energy
content can be added in solid foods when the infant is old enough.

●High-energy supplements, such as glucose polymers (which provide 8 cal/teaspoon) or

medium chain triglyceride oil (which provides 7.7 cal/mL), are used to fortify formula or solid
foods [62,66]. MCT oil is useful because it is calorically rich, and it is readily absorbed by
patients with cholestasis because it does not require micellar solubilization.

●Despite these measures, many infants and children with BA require supplemental feeding by
nasogastric tube because they are unable to take enough energy by mouth to meet their
increased nutritional needs. Gastrostomy tubes are not recommended because many patients
develop portal hypertension, leading to gastric varices and the propensity to develop varices
around the gastrostomy tube site. Candidates for nasogastric feeds are identified by poor
weight gain and/or poor linear growth. Proactive management is recommended because the
malnutrition may worsen the overall prognosis, with or without liver transplantation [62]. (See
"Overview of enteral nutrition in infants and children".)

Fat-soluble vitamin supplements — All jaundiced infants and children with BA should be given
supplements of fat-soluble vitamins. Once jaundice resolves and vitamins are replete, children
can be transitioned to standard multivitamins. Nevertheless, routine monitoring of vitamin
levels should continue (table 3).

Deficiencies of fat-soluble vitamins are common in patients with BA. In a series of 29 patients
with BA, serologic deficiencies of vitamins A and E and radiographic evidence of vitamin D
deficiency were reported despite establishment of bile flow by hepatoportoenterostomy [68].
Vitamin deficiencies occur despite recommended supplementation and are particularly
common among patients with residual cholestasis after Kasai HPE (defined in this study as
serum total bilirubin ≥2 mg/dL [34 micromol/L]) [69]. In one study, 81 percent of infants were
found to be Vitamin D deficient before HPE, and vitamin D deficiency persisted post-HPE
despite aggressive supplementation [70]. Therefore, vitamin levels should be monitored
frequently (ie, several times in the first year), starting at the first month after HPE, in order to
adjust supplements appropriately for deficiencies or toxicities (table 3).

Infants with biliary atresia and prolonged jaundice may be deficient in vitamin K. Patients
should receive supplementation with oral vitamin K, and should be monitored for
coagulopathy. Some infants may require parenteral vitamin K supplementation due to poor
absorption of oral medications in the setting of severe cholestasis.

Complications — Children with successful bile drainage following HPE must be followed closely
for complications including ascending cholangitis and portal hypertension. In addition, all
patients should be routinely monitored for fat-soluble vitamin deficiencies as described above.
Ascending cholangitis — Cholangitis is a common complication in patients with BA who have
undergone a successful Kasai HPE (excluding post-surgical complications). The incidence of
cholangitis in these patients is between 40 and 90 percent, with the majority of patients
experiencing at least one episode prior to two years of age [57,71]. These patients are at risk
for cholangitis because of the abnormal anatomy and bacterial stasis in the region of the roux
limb. Clinicians should have a high level of suspicion for cholangitis in children presenting with
fever without a clear source of infection, especially if the fever is accompanied by acholic
stools, irritability, and laboratory abnormalities. By contrast, patients with an unsuccessful
Kasai (ie, in which bile drainage is not achieved) have a low risk for ascending cholangitis but
are still at risk for other infections and sepsis.

Because cholangitis can be life threatening and may impact long- and short-term outcomes
[71,72], most clinicians prescribe prophylactic antibiotics in the first year of life. Small
nonrandomized trials suggest that the benefits of antibiotic prophylaxis outweigh the risks of
antibiotic resistance [73,74]. As an example, in one series infants treated with prophylactic
antibiotics had half the rate of cholangitis as compared with infants in a historical control
group [73]. Either trimethoprim-sulfamethoxazole (4 mg/kg/day trimethoprim and 20
mg/kg/day sulfamethoxazole) or neomycin (25 mg/kg/day divided four times daily) appear to
be equally effective in decreasing the incidence of cholangitis [73]. There may be evidence to
suggest that treatment with probiotics can afford a prophylactic effect that is similar to that of
antibiotics, but further studies are needed [75].

Recurrent cholangitis may predict the need for liver transplantation as it can lead to
progressive cirrhosis [71]; however, one episode of cholangitis does not predict early
transplantation [8].

Portal hypertension — The chronic hepatobiliary inflammation characteristic of BA leads to

progressive biliary cirrhosis. Biliary cirrhosis causes portal hypertension, which can lead to
variceal bleeding and ascites. Development of splenomegaly or declining platelet counts after
Kasai HPE suggest the possibility of evolving portal hypertension.

In a registry study of 163 children with BA in North America who had not undergone liver
transplantation (average age 9.2 years), half had definite portal hypertension [76]. Among
those with portal hypertension, 53 percent had a history of variceal bleeding, 17 percent had
ascites, and 34 percent had reduced hepatic synthetic function (PT >15 seconds or albumin <3
g/dL). Recurrent variceal bleeding and refractory ascites are indications for liver
transplantation [77,78]. (See 'Liver transplantation' below.)

If portal hypertension leads to variceal bleeding, this complication is often controlled with
sclerotherapy or banding. After the first variceal bleed, sclerotherapy or band ligation is
instituted on a repeat basis with the ultimate goal of complete variceal obliteration. Some
centers perform surveillance endoscopy to gauge the size and status of developing varices in
patients who demonstrate clinical and ultrasonographic signs of portal hypertension following
the Kasai procedure. In a series of 47 children with BA managed with endoscopic surveillance,
varices developed in about half of the children, at a mean of 19 months (range 4 to 165
months) after successful Kasai HPE [79]. Other centers begin routine surveillance endoscopies
only after the patient has experienced the first variceal bleed. A consensus statement on the
management of portal hypertension in children suggests that primary prophylaxis of
esophageal varices is not indicated except in extenuating circumstances, such as when the
child is not in reasonable proximity to emergency care [80].
If ascites develops and is severe enough to compromise respiratory function, it is usually
treated with paracentesis followed by chronic administration of diuretics, beta-blockers, salt
and/or water dietary restriction, or a combination of these interventions.

LIVER TRANSPLANTATIONThe majority of individuals with BA eventually require liver

transplantation; indeed BA is the most common indication for liver transplantation in infants
and children. In the current era, at least 60 to 80 percent of patients with BA will require liver
transplantation, even with optimal management. (See 'Prognosis' below.)

The indications for liver transplantation for patients with BA include [62,81-83]:

●Primary failure (lack of bile drainage) of the Kasai hepatoportoenterostomy (HPE)

•Prompt referral for liver transplantation evaluation is recommended if total bilirubin is >6
mg/dL (100 micromol/L) three months or more beyond HPE.

•Referral for liver transplantation evaluation also should be considered if total bilirubin is
persistently 2 to 6 mg/dL (34 to 100 micromol/L) three months or more beyond HPE.

●Refractory growth failure – Referral for transplantation should be considered for patients
with moderate or severe growth failure that does not respond to intensive nutritional support.

●Complications of portal hypertension (if these cannot be managed with other measures)

•Repeated variceal bleeding

•Refractory ascites that compromises respiratory, bowel, or renal function

•Hepatopulmonary syndrome

•Portopulmonary hypertension

●Progressive liver dysfunction

•Intractable pruritus

•Refractory coagulopathy

Among patients transplanted before two years of age, persistent cholestasis (often
complicated by growth failure) and recurrent or resistant cholangitis are the most common
indications for liver transplantation.

Although it is clear that the vast majority of BA patients will ultimately require liver
transplantation, preemptive transplants should be deferred as there are advantages to
transplanting older and larger patients. Because the outcomes of liver transplantation improve
for infants with weights >10 kg, as compared to smaller infants, transplantation of infants with
persistent cholestasis may be postponed if growth can be achieved and the infants are
otherwise stable. Supplemental nasogastric tube feedings are often necessary to attain
adequate growth. The cholestasis may cause chronic pruritus, which often responds to medical
therapy. (See "Pruritus associated with cholestasis".)

For those children who require liver transplantation, prognosis is generally good. In the United
States, the one-year patient- and liver-graft survival rates for pediatric patients undergoing
primary liver transplant for BA are 95.8 and 88.8 percent, respectively [84]. In international
series, long-term survival is approximately 70 to 80 percent at both 5 and 10 years, and these
rates continue to improve in more recent case series [53,85-89].
BA patients can receive whole or segmental deceased donor grafts, as well as segments from a
living donor [88]. The liver transplant surgery in BA patients is complicated by presence of
intra-abdominal adhesions attributed to previous HPE. Postoperative outcomes appear to be
less favorable in the subset of BA patients with BASM, due to the enhanced difficulty
associated with liver dissection and vascular reconstruction in these patients [87]. Poor
nutrition is associated with increased mortality either while awaiting transplantation or after
the procedure [90]. Thus, vigorous nutritional support, including nasogastric feeds, is essential
in the pre- and postoperative care of these patients. (See 'Nutrition' above.)

PROGNOSISAlthough long-term prognosis for BA patients is variable, the complementary and

sequential approach of hepatoportoenterostomy (HPE) and liver transplantation affords long-
term survival, with upwards of 90 percent of BA patients surviving into adulthood [91,92].
Importantly, waitlist and post-transplant mortality is higher in patients undergoing transplant
earlier in life. In a large series, patients undergoing transplant when they were less than two
years of age had five-year survival of 93.8 percent, compared with 97.1 percent for those
transplanted after two years of age [84]. This observation underscores the importance of
achieving biliary drainage with HPE and delaying transplantation when possible.

Infants and young children with BA are at increased risk for neurodevelopmental delays at one
and two years of age, particularly if the HPE was not successful [93]. The risk is correlated with
poor growth and ascites, both of which are markers for more advanced liver disease.

Survival without transplantation — Overall survival with native liver (ie, without
transplantation) ranges from 30 to 55 percent at five years, 30 to 40 percent at 10 years, and
20 to 40 percent at 20 years [41,85,92,94-100]. The long-term outcomes are illustrated by the
following series:

●Among 1107 patients diagnosed with BA between 1986 and 2009 in France, 94 percent
underwent the Kasai HPE, leading to initial clearance of jaundice in 38 percent [92]. Survival
with the native liver was 40 percent at 5 years, 36 percent at 10 years, and 30 percent at 20
years of age. Overall patient survival was 81 percent at 5 years, 80 percent at 10 years, and 77
percent at 20 years of age.

●Among 80 patients who underwent the procedure between 1970 and 1986 in Japan, the 5-,
10-, and 20-year survival rates with native livers of 63, 54, and 44 percent, respectively [99].
Half of the 20-year survivors had cirrhosis, and 20 percent went on to liver transplant or death
within a few years.

●Among 104 patients who underwent the procedure between 1977 and 1988 in The
Netherlands, 27 percent were alive with native liver 20 years later [100]. Twenty-one percent
of the long-term survivors had normal liver biochemical tests and no evidence of cirrhosis.

●Among 34 patients with BA who underwent Kasai HPE between 1994 and 2011, survival with
the native liver was 87.6 percent at 5 years, 76.9 percent at 10 years, and 48.5 percent at 15
years [37]. This represents substantial improvement in outcomes compared with earlier series,
possibly due to earlier identification of affected infants due to a national screening program
using stool color cards. (See 'Signs and symptoms' above.)

In addition to complications from portal hypertension and late-onset cholangitis, the risk of
developing cancer in the native liver remains an important concern. Careful monitoring and
treatment of these late complications is essential. Pregnancy in female survivors of BA is not
without risk, and the pregnancy must be monitored to ensure the health and safety of the
mother and child.

Given the improvements in early identification of infants with BA, and advances in medical
therapy after Kasai HPE, including prophylaxis against cholangitis and improvements in
nutrition and bile flow, it is reasonable to expect that long-term survival from current cases
will exceed that of these older series. Experimental areas of therapy such as anti-fibrotic or
antiinflammatory agents may improve outcomes in the future.

Predictors of the need for transplantation — Although performance of the Kasai HPE clearly
improves survival overall, the long-term prognosis is difficult to predict. The three most
important prognostic factors for surgical outcome are younger age at the time of HPE, the
expertise of the surgeon and care center at which the procedure is performed, and the
decrease in serum bilirubin in the first few months after HPE.

Many case series have documented better outcomes when HPE is performed before 60 days of
age and poorer outcomes after 90 days of age [41,85,94,95]. As an example, in a series of 349
infants diagnosed and treated for biliary atresia in Canada, older age at time of HPE was
associated with a progressive decrease in patient survival with the native liver [53]. Among
infants who underwent HPE at ≤30 days, 31 to 90 days, and ≥90 days, the survival with the
native liver at four years of age was 49, 36, and 23 percent, respectively. In Taiwan, after
implementation of a protocol using universal screening for infant stool color increased the rate
of accomplishing HPE before 60 days of life from 50 to 66 percent, improvements in several
clinically important outcomes were seen: the rate of jaundice-free survival with the native liver
at three years of age improved from 32 to 57 percent, and the rate of overall survival at five
years of age improved from 56 to 89 percent [101]. However, the time at which early is early
enough and late is too late is controversial [102].

Surgical success is dependent on the expertise of the center and surgeon. Although
controversial, it appears that a center that performs at least five Kasai procedures per year has
a better success rate, as measured by 5- or 10-year long-term survival with the native liver
[86,94,103]. Another surgical factor is anatomic pattern of biliary atresia identified at time of
Kasai hepatoportoenterostomy. Children born without atresia at the porta hepatis (Ohi
classification 1) have the lowest risk of death or transplantation by two years of age [104].

Among all variables, serum bilirubin post HPE appears to be the most predictive biomarker of
outcome. Data suggest that the serum total bilirubin level measured three months after Kasai
HPE is predictive of native liver survival [8,105]. In a prospective cohort, among patients with
total bilirubin <2 mg/dL three months post-Kasai HPE, two-year survival without
transplantation was 86 percent [105]. Among those with total bilirubin ≥2 mg/dL three months
post-Kasai HPE, survival without transplantation was only 20 percent. Infants with elevated
bilirubin were also more likely to develop poor weight gain, hypoalbuminemia, and
coagulopathy.

SOCIETY GUIDELINE LINKSLinks to society and government-sponsored guidelines from selected

countries and regions around the world are provided separately. (See "Society guideline links:
Pediatric liver disease".)

SUMMARY AND RECOMMENDATIONSBiliary atresia (BA) is a progressive, idiopathic, fibro-

obliterative disease of the extrahepatic biliary tree that presents with biliary obstruction in the
neonatal period, and is the most common indication for liver transplantation in children.
●BA may occur in isolation (70 percent), in association with laterality anomalies such as situs
inversus or asplenia (10 to 15 percent), or with other congenital malformations (10 to 15
percent). Those with laterality anomalies have a somewhat worse prognosis. (See
'Introduction' above.)

●The causes of BA are not well established and are probably multifactorial; genetic factors
may play a permissive role in some cases, but infectious, toxic, or immunologic mechanisms
are probably involved. (See 'Pathogenesis' above.)

●Most infants with BA are born at full term, have a normal birth weight, and initially thrive and
seem healthy. Scleral icterus and/or generalized jaundice typically develop by eight weeks of
age. Infants may also have acholic (very pale colored) stools (see "stool color card" for
examples), dark urine, and/or a firm liver and splenomegaly. Laboratory testing reveals
elevation in serum conjugated bilirubin (>2 mg/dL [34 micromol/L]) and mild or moderate
elevations in serum aminotransferases with a disproportionately increased GGTP. (See 'Clinical
features' above.)

●The diagnosis of BA is made with a series of imaging and laboratory tests and liver biopsy to
exclude other causes of cholestasis. Infants should be evaluated as rapidly as possible because
the success of the surgical intervention diminishes progressively with older age at surgery.
Because timing is crucial, some infants (eg, those who are eight weeks or older or with a high
clinical suspicion of BA) may not require each diagnostic step. (See 'Evaluation' above.)

●The definitive diagnosis of BA is made by a cholangiogram. This is typically performed

intraoperatively; if the diagnosis of BA is confirmed, the surgeon performs a
hepatoportoenterostomy (HPE, also known as a Kasai procedure) (figure 1). (See
'Cholangiogram' above and 'Diagnosis' above.)

●We recommend that all infants with BA undergo a Kasai HPE (Grade 1B). This surgery should
be performed as soon as the diagnosis of BA can be made and preferably before 60 days of
age. This is because younger age at the time of the Kasai HPE is associated with better
outcomes (ie, higher likelihood of resolution of cholestasis and longer survival with the native
liver). (See 'Kasai procedure' above and 'Predictors of the need for transplantation' above.)

●We suggest that infants and children be treated with ursodeoxycholic acid (UDCA) after Kasai
HPE (Grade 2C). We do not recommend treatment with glucocorticoids (Grade 1A). (See
'Choleretics' above and 'Glucocorticoids (unproven benefit)' above.)

●Infants with BA who are jaundiced are at risk for fat-soluble vitamin deficiencies and should
be treated with supplements of fat-soluble vitamins and monitored for fat-soluble vitamin
deficiencies (table 3). In addition, they should be given high calorie formula or other nutritional
supplements as required to sustain normal rates of growth. If weight gain is below normal
despite these measures, nasogastric feeds should be administered to optimize growth.
Vigorous nutritional support is also indicated for non-cholestatic infants with BA. (See
'Nutrition' above.)

●After Kasai HPE infants and children are at risk for ascending cholangitis. Some data have
shown that repeated episodes of cholangitis can hasten the progression of liver disease. To
reduce this risk, we suggest treating all patients with prophylactic antibiotics in the first year of
life (Grade 2B). (See 'Ascending cholangitis' above.)
●After Kasai HPE, if there is persistent jaundice three months later then the patient should be
referred for liver transplant evaluation. Other indications for early liver transplantation include
failure to thrive despite vigorous nutritional rehabilitation. (See 'Liver transplantation' above.)

●In the current era, at least 60 to 80 percent of patients with BA will eventually require liver
transplantation. Indications for liver transplantation include complications of portal
hypertension (recurrent variceal bleeding or intractable ascites), growth failure, and
progressive liver dysfunction. (See 'Liver transplantation' above.)

●A minority of patients with BA treated with Kasai HPE survive to 20 years or more without
liver transplantation. However, many of these patients have chronic liver disease with cirrhosis
and portal hypertension. (See 'Survival without transplantation' above.)

GRAPHICS
Laboratory testing for evaluating a neonate or young infant with suspected cholestatic liver
disease

◊ Infants must be off of ursodeoxycholic acid for at least five days prior to urine collection for bile acid
analysis, because the FAB-MS signature of the drug overlaps with some of the abnormal bile acid
metabolites seen in BASD.
§ Individual gene sequencing can be done if the clinical presentation suggests a specific diagnosis, such as
Alagille syndrome. For screening of multiple genes associated with inherited cholestasis, next generation
sequencing panels are available. Each panel interrogates about 20 to 50 genes.
 Kasai hepatoportoenterostomy

In the Kasai hepatoportoenterostomy the bile ducts are excised and a limb of jejunum is
anastamosed to the liver. The distal duodenum is anastomosed to the jejunal limb to create a
Roux-en-Y configuration.