To the Editor: Distinction between the two broad categories of neonatal cholestasis (Neonatal hepatitis and Biliary atresia) is of important prognostic implication because early surgical intervention before 8–10 wk, significantly improves the outcome of obstructive pathology.

Despite this understanding, we notice delayed referrals of Biliary atresia (BA). Over last five years, we managed 16 cases of BA, 12 presented after 3 mo of age, while 4 presented between 2 and 3 mo of age. Many patients were not considered as biliary atresia by their treating clinicians as ultrasound demonstrated gallbladder. Without any further investigation they were managed as Hepatitis. Thus, missing the valuable time and causing further delay in management.

Although ultrasonography is used as one of the first imaging modalities to visualize hepatobiliary system, but is least sensitive and specific for BA and its findings should be confirmed by scintigraphy or liver biopsy. Sensitivity and specificity of hepatobiliary scintigraphy in diagnosis of BA is reported as 90 % and 80 % respectively. Respective values for liver biopsy are 92.5 %, 88.9 % and for ultrasonographic analysis are 41.7 % and 80.9 % [1].

Immense patience is required to examine a baby with cholestasis on ultrasound. Adequate sedation to avoid a crying child is important for proper study. Multiple cross section scans between ribs are taken to examine liver, gallbladder, and porta hepatis. Gall bladder size in 3–4 h fasting status and 1, 2, and 3 h postprandial is determined. Manifestations of sonograms in BA are (1) Triangular cord sign at the porta hepatis, (2) Manifestations of gallbladder is classified into 4 types: absence of gall bladder, vacant and flat gallbladder, flat and small gallbladder (less than 1.5 cm), and gallbladder with almost normal size and appearance. (3) Degree of hepatomegaly and echogenicity of liver parenchyma [2]. Prominent hepatic artery, gall bladder abnormalities and triangular cord sign are regarded as supporting features of BA [3, 4].

It emphasizes that visualization of gallbladder in an ultrasonography is not enough to rule out BA. As pediatric radiologists are not available everywhere, it is important for the pediatricians to understand sonographic findings and request sonologist to see for all these features. If required, repeat sonography after a week or proceed with further investigations, because ultimately onus of making diagnosis and correlating investigations lies with the treating doctor.