In biliary atresia, cholangiography still remains the diagnostic gold standard.

Early diagnosis of biliary atresia (BA) is essential to maximize the success of Kasai portoenterostomy. We read with interest the recent study reporting excellent diagnostic performance of abdominal ultrasonography combined with serum gamma-glutamyl transferase (GGT) for the diagnosis of BA. While these findings are encouraging, their applicability to younger infants deserves caution, as the study cohort was diagnosed relatively late. During the earliest stages of BA, ultrasonographic findings, serum GGT levels, and even liver biopsy may be less reliable, increasing the risk of delayed diagnosis. When BA remains clinically suspected, preserving the therapeutic window for Kasai portoenterostomy should take precedence, and cholangiography should remain the diagnostic gold standard rather than be delayed by repeated non-invasive investigations.