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Hepatic subcapsular or capsular flow in biliary atresia: is it useful imaging feature after the Kasai operation?

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To evaluate the implications of hepatic subcapsular and capsular flows using ultrasonography (US) in children after Kasai operation.


Children who underwent liver US including color Doppler US and microvascular imaging (MVI) from May 2017 to October 2017 were retrospectively included. Children who underwent the Kasai operation for biliary atresia were included in the Kasai group and children with normal liver were included in the control group. Using US results, the number of intrahepatic biliary cysts and the maximum diameter of the spleen were evaluated in the Kasai group. Liver stiffness values were included when patients in the Kasai group had transient elastography (TE) or shear wave elastography (SWE) results. Hepatic subcapsular and capsular flows on color Doppler US and MVI were compared between the two groups using the following scores: 0, no flow reaching the hepatic capsule; 1, any flow reaching the hepatic capsule; and 2, contiguous hepatic capsular flow. The logistic regression test was used to identify associations between age, intrahepatic biliary cysts, spleen size, SWV, TE results, and flow scores measured on Doppler US and MVI in the Kasai group using the odds ratio (OR) and 95% confidence interval (CI).


A total of 65 children (mean 7.6 ± 5.3 years), 44 in the Kasai group and 21 in the control group, were included. In the control group, one child had score 1 on MVI and others had score 0 on both Doppler US and MVI. Among the Kasai group, 28 children (63.6%) had score 1, while others had score 0 using Doppler US. Using MVI, 24 children (54.5%) had score 2, 18 children had score 1, and one child had score 0. In the Kasai group, increased liver stiffness on TE was the only factor significantly associated with the presence of subcapsular flow on color Doppler US (OR 1.225, 95% CI 1.020–1.470) and increased spleen size was the only factor significantly associated with increased flow scores on MVI (OR 1.397, 95% CI 1.002–2.724).


Detection of hepatic subcapsular, capsular flows on US would be meaningful for children after receiving the Kasai operation.

Key Points

• Hepatic subcapsular or capsular flows can be useful not only for the diagnosis but also for the postoperative follow-up in patients with biliary atresia.

• Increased liver stiffness and splenomegaly after the Kasai operation were associated with presence of subcapsular or capsular flow on ultrasonography.

• Evaluation of hepatic subcapsular and capsular flows could be needed to assess disease progression after receiving the Kasai operation.

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Fig. 1



Biliary atresia


Confidence interval


Liver stiffness values


Microvascular imaging


Odds ratio




Supersonic shear wave imaging


Shear wave elastography


Shear wave velocity


Transient elastography




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The authors state that this work has not received any funding.

Author information

Correspondence to Hyun Joo Shin.

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The scientific guarantor of this publication is Hyun Joo Shin.

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The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

The statistical methods of this study were reviewed by Kyunghwa Han, PhD, who is a biostatistician and research assistant professor in the Center for Clinical Imaging Data Science, Department of Radiology, Yonsei University College of Medicine.

Informed consent

Written informed consent was waived by the Institutional Review Board.

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Institutional Review Board approval was obtained.


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• Performed at one institution

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Lee, S., Kim, M., Lee, M. et al. Hepatic subcapsular or capsular flow in biliary atresia: is it useful imaging feature after the Kasai operation?. Eur Radiol (2020). https://doi.org/10.1007/s00330-020-06656-5

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  • Biliary atresia
  • Child
  • Ultrasonography
  • Liver
  • Splenomegaly