Biliary atresia (BA) stands as the primary reason children require liver transplants, but despite surgical correction, the majority of infants ultimately develop liver failure. A thorough analysis of recent findings now highlights the gut microbiome — the dense population of bacteria residing in the intestines — as a pivotal element in how this severe illness progresses. The results indicate that infants diagnosed with BA possess a notably disturbed gut microbial environment, characterized by an excess of pathogenic bacteria and a significant reduction in helpful microbes such as Bifidobacterium. These microbial disruptions are detectable prior to surgery and are strongly associated with worse prognoses, including unsuccessful jaundice resolution and accelerated disease advancement. The review proposes that the gut-liver axis — the bidirectional communication network between the intestines and the liver — may be essential for understanding why certain infants experience better outcomes than others.
BA is a progressive condition involving fibrous obliteration of the bile ducts, affecting roughly one in 10,000 to 15,000 newborns globally. The Kasai portoenterostomy, the standard operative treatment, aims to reestablish bile drainage by linking the liver directly to the small intestine. Nevertheless, only around 60% of infants achieve sufficient bile flow, and even those who do frequently suffer ongoing liver damage. Despite many years of investigation and numerous post-operative therapies — including antibiotics, bile acid agents, and steroids — the majority of patients ultimately require liver transplantation by early adulthood. The gut microbiome has become a significant factor in liver disorders, yet its involvement in neonatal and infant liver conditions — during a phase when the microbial community is still maturing — has remained largely unexamined. Given these difficulties, there is a pressing requirement for comprehensive research into how the gut-liver-microbiota pathway affects BA development and patient outcomes.
A new review published on January 7, 2026, in the World Journal of Pediatric Surgery compiles current knowledge regarding the gut microbiome in BA. The research, led by Dr. Vandana Jain, analyzes microbial composition in patients both before and after the Kasai procedure, identifies recurring patterns of dysbiosis, and investigates how these microbial disruptions may contribute to disease progression through pathways involving bile acid metabolism, bacterial translocation, and immune system regulation.
The review uncovers a notably uniform microbial signature in BA across various studies, in spite of differences in patient groups and laboratory techniques. Prior to surgery, infants with BA exhibit a marked alteration in microbial makeup compared to healthy infants — with pathobionts including Streptococcus, Enterococcus, Veillonella, Klebsiella, and Clostridium becoming dominant, while beneficial commensals such as Bifidobacterium, Faecalibacterium, and Blautia are significantly reduced. This pattern continues and even intensifies following the Kasai procedure, driven not only by ongoing cholestasis but also by clinical practices like decreased breastfeeding rates and the standard use of broad-spectrum preventive antibiotics, both recognized for suppressing helpful bacteria. Importantly, the reduction of Bifidobacterium has been connected to poorer jaundice clearance, heightened liver fibrosis, and a greater likelihood of post-surgical cholangitis — a severe and frequent complication that further harms the liver. The review also emphasizes emerging evidence that microbial metabolites, especially short-chain fatty acids like acetate and butyrate, may serve protective functions, with butyrate demonstrating potential anti-fibrotic properties in experimental models. Disruptions in bile acid metabolism, driven by gut bacteria via enzymes such as bile salt hydrolase, further worsen the situation, generating a harmful cycle of liver injury and microbial imbalance.
“The gut microbiome is not merely a passive observer in BA — it seems to be an active contributor to disease progression,” the authors stated. “We are observing consistent trends where harmful bacteria proliferate and beneficial ones like Bifidobacterium are diminished, and these alterations correlate with how well patients fare after surgery. The encouraging aspect is that the microbiome can be influenced. If we can determine how to safeguard and reestablish a healthy microbial ecosystem in these infants, we might be able to alter the course of their illness.”
These discoveries create opportunities for novel therapeutic strategies in BA, a condition for which treatment options have stayed restricted for many years. Approaches that modify the microbiome — such as probiotics, prebiotics, and possibly fecal microbiota transplantation — have demonstrated effectiveness in adult liver diseases and could be adjusted for infants. Early trials involving Lactobacillus rhamnosus GG have produced inconsistent outcomes, indicating that strain selection, timing, and combination methods will be essential. The review also advocates for a reassessment of current clinical practices, including the extensive use of preventive antibiotics right after the Kasai procedure, which may inadvertently disturb the developing microbiome. By incorporating microbiome science into clinical care, researchers aim to enhance native liver survival and decrease the necessity for liver transplantation in these vulnerable infants.
References
DOI
10.1136/wjps-2025-001068
Original Source URL
https://doi.org/10.1136/wjps-2025-001068
Lucy Wang
BioDesign Research
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