Non biliary atresia - Neonatal hepatitis group (Non BA-NH group): The first group, of patients commonly presenting in the first month of life, is that in which treatable infections (septicemia, urinary tract infections, malaria, toxoplasmosis and tuberculosis) or treatable metabolic disorders (galactosemia) are diagnosed. These are treated aggressively with appropriate therapy, which usually halts the progress of the liver disease.

In this group, we also include treatable surgical causes such as choledochal cyst. Choledochal cysts require complete surgical excision and an entero- biliary anastomosis.

Suspected biliary atresia group (BA Group): The second and largest group, is of patients in whom none of the above conditions are diagnosed and the hepatobiliary scan does not show excretion into the gut upto 24 hrs. This group of patients irrespective of the results of the viral studies (such as the TORCH tests) should undergo an early exploratory laparotomy with a pre-operative cholangiogram. If the cholangiogram confirms atresia of the biliary tree then a portoenterostomy (Kasai operation) is performed.

Suspected neonatal hepatitis group (NH Group): The third group, is of patients in whom none of the non BA-NH causes have been diagnosed but the hepatobiliary scan shows definite excretion of tracer into the gut within 24 hrs. Patients in this group may test positive for viral studies- especially cytomegalovirus (CMV). Though it is correct to label these cases as neonatal hepatitis at this stage, they have to be carefully followed up on a weekly basis, because the same etiopathological process may lead to atresia later. It is our policy to follow up these cases with hepatobiliary scans every fortnightly till the bilirubin levels show a sustained downward trend. If at any point of time the scan becomes obstructive (no excretion of tracer into the gut upto 24 hrs.) then an exploratory laparotomy with an operative cholangiogram is performed. If viral hepatitis is diagnosed then use of anti-viral agents may be considered. This is the only group of patients in whom we perform a closed liver biopsy to confirm the diagnosis and study the extent of the liver disease. Although in some leading international centers where experts in pediatric hepatic pathology are available liver biopsies are done in every case.