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Endoscopic retrograde cholangiopancreatography in patients with neonatal cholestasis: an additional diagnostic tool for selected indications.

Neonatal cholestasis is a rare condition characterised by jaundice and conjugated hyperbilirubinemia. It may be related to a wide range of aetiologies, including obstruction of bile ducts, metabolic or genetic disorders, immaturity of the liver, parenteral nutrition, drug toxicity, and infections (1). Urgent medical therapy is required to correct potential clotting abnormalities because of vitamin K absorption deficiency, which may lead to severe bleeding (2). Among the various causes of neonatal cholestasis, biliary atresia (BA) needs urgent diagnosis and therapy because the success of the Kasai operation is closely related to the age of the patient; the prognosis declines progressively with increasing age at surgery, and the best long-term results are obtained when children are operated on in the first month of life (3,4). BA can be highly suspected in the presence of the clinical triad of jaundice, acholic stools, and hepatomegaly (5). If, additionally, ultrasound scans, after strict fasting (the child ideally receiving intravenous fluids to prevent agitation and hypoglycaemia), show shrunk or absent gallbladder, then the probability of BA is high (6), and surgical exploration can be performed after rapid exclusion of the most common medical causes of neonatal cholestasis (7). However, in some cases, the clinical presentation may be less characteristic, and the gallbladder may appear normal on ultrasound scans, thus other investigations are required for diagnosis. Liver biopsy is useful because it may orient the diagnosis towards obstruction of large bile ducts (bile plugs, biliary pro-