A 7-week-old term infant has persistent jaundice with pale acholic stools and dark urine. Total bilirubin is predominantly conjugated. Ultrasound shows an absent or contracted gallbladder. Which investigation best distinguishes biliary atresia from neonatal hepatitis?

• A Serum gamma glutamyl transferase level
• B Magnetic resonance colonography
• C Percutaneous transhepatic cholangiography under ultrasound guidance
• D Intraoperative cholangiography combined with liver biopsy ✓

Explanation

When non-invasive tests cannot separate biliary atresia from neonatal hepatitis, operative cholangiography showing no opacification of extrahepatic ducts, together with wedge and needle biopsy demonstrating bile duct proliferation and portal fibrosis, remains the diagnostic gold standard. A rising GGT supports cholestasis of atresia but does not distinguish the two reliably. Percutaneous transhepatic cholangiography is technically difficult when ducts are obliterated, which they typically are in atresia.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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