A term newborn develops conjugated hyperbilirubinemia at 3 weeks of age with acholic stools. Percutaneous liver biopsy shows portal edema, marked proliferation of small bile ductules at the portal margins, and inspissated bile plugs within dilated ductular lumens. Which finding on this biopsy most strongly supports extrahepatic biliary atresia over neonatal hepatitis?

• A Multinucleated giant cell transformation of hepatocytes
• B Bile plugs within proliferating interlobular ductules ✓
• C Extramedullary hematopoiesis in portal tracts
• D Perisinusoidal collagen deposition

Explanation

Bile plugs within proliferated ductules indicate downstream mechanical obstruction, the hallmark pointing toward biliary atresia and away from neonatal hepatitis, which shows predominantly lobular disarray and giant cell transformation without ductular plugging. Giant cell change (option A) actually favors neonatal hepatitis. Extramedullary hematopoiesis is normal in infant livers and nonspecific. Early surgical Kasai portoenterostomy before 60 days depends on recognizing these obstructive changes promptly.

Reference: Robbins and Cotran Pathologic Basis of Disease, 10th ed.

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