Pe d i a t r i c I m a g i n g • O r i g i n a l R e s e a r c h
Zhou et al.
Ultrasound for the Diagnosis of Biliary Atresia
Pediatric Imaging
Original Research
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved
FOCUS ON:
Luyao Zhou1
Quanyuan Shan
Wenshuo Tian
Zhu Wang
Jinyu Liang
Xiaoyan Xie
Zhou L, Shan Q, Tian W, Wang Z, Liang J, Xie X
Keywords: biliary atresia, gallbladder, pediatrics,
triangular cord sign, ultrasound
DOI:10.2214/AJR.15.15336
Received July 23, 2015; accepted after revision
December 13, 2015.
Supported by National Natural Science Foundation of
China (NO: 81371555) and Natural Science Foundation of
Guangdong province (NO: 2015A030313060).
1 common, with frequency ranging from 1 in
All authors: Department of Medical Ultrasonics,
Institute for Diagnostic and Interventional Ultrasound,
The First Affiliated Hospital, Sun Yat-Sen University,
58 Zhongshan Rd 2, Guangzhou, 510080, China. Address
correspondence to X. Y. Xie (xxy1992sys@163.com).
This is an ahead-of-print version of the article; the final
version will appear in the May 2016 issue of the AJR.
WEB
This is a web exclusive article.
Supplemental Data
Available online at www.ajronline.org.
AJR 2016; 206:W1–W10
0361–803X/16/2065–W1
© American Roentgen Ray Society
AJR:206, May 2016 W1
Ultrasound for the Diagnosis of
Biliary Atresia: A Meta-Analysis
OBJECTIVE. The purpose of this meta-analysis was to summarize the evidence on the
accuracy of various ultrasound findings for excluding a diagnosis of biliary atresia.
MATERIALS AND METHODS. We searched MEDLINE and the Web of Science da-
tabases for the period from January 1990 to May 2015. To be included, studies had to satisfy
two criteria. First, the data needed to include 2 × 2 contingency data on the diagnostic accura-
cy of ultrasound in identifying biliary atresia in at least 10 patients with and 10 patients with-
out disease. Second, the study needed to use surgery or biopsy for biliary atresia and surgery,
biopsy, clinical follow-up, or some combination of the three as the reference standard for the
exclusion of biliary atresia. The methodologic quality of each study was assessed with version
2 of the Quality Assessment of Diagnostic Accuracy Studies tool. Estimated sensitivity and
specificity of each ultrasound characteristic were calculated using a random-effects model.
RESULTS. Twenty-three studies published during 1998–2015 were included. Summary
sensitivity and specificity were 0.85 (95% CI, 0.76–0.91) and 0.92 (95% CI, 0.81–0.97), re-
spectively, for gallbladder abnormalities in 19 studies; 0.74 (95% CI, 0.61–0.84) and 0.97 (95%
CI, 0.95–0.99), respectively, for triangular cord sign in 20 studies; and 0.95 (95% CI, 0.70–
0.99) and 0.89 (95% CI, 0.79–0.94), respectively, for the combination of the triangular cord
sign and gallbladder abnormalities in five studies. Subgroup analysis of an absent gallbladder
in 10 studies yielded a summary specificity of 0.99 (95% CI, 0.93–1.00).
CONCLUSION. The triangular cord sign and gallbladder abnormalities are the two
most accurate and widely accepted ultrasound characteristics for diagnosing or excluding
biliary atresia. Other ultrasound characteristics are less valuable for diagnosis or exclusion
of biliary atresia.
iliary atresia remains one of the described as useful indicators for diagnosing
B most serious liver diseases af-
fecting infants and can be fatal if
untreated [1]. The disease is un-
biliary atresia [11–17]. Before the identifica-
tion of the “triangular cord” sign by Choi et
al. [13] in 1996, gallbladder abnormalities
were the key indicators for identifying bili-
5000 to 1 in 20,000 live births worldwide [2– ary atresia. These abnormalities included ab-
5]. Surgical drainage by Kasai portoenteros- sence of a gallbladder, small gallbladder size,
tomy is more successful if performed during abnormal shape and wall of the gallbladder,
the early stage of the disease [6–8]. However, and no contraction of the gallbladder. Abnor-
in infants with conjugated hyperbilirubine- mal wall features included irregularity of the
mia, identifying biliary atresia in the early wall and thinner wall without mucosa [10,
stage of the disease is challenging [9, 10]. 14, 15, 18, 19]. An abnormally shaped gall-
Current modalities and techniques for bladder would typically be one with an irreg-
evaluating cholestatic jaundice include ultra- ularly compromised lumen [10, 14, 18, 20].
sound, hepatobiliary scintigraphy, MR chol- No contraction of the gallbladder was used to
angiography, and liver biopsy. Among these, indicate a gallbladder that does not contract
ultrasound is recommended as the initial after feeding [21, 22]. Gallbladder abnormal-
screening examination [1, 11] because it is ities can yield both sensitivities and speci-
cost-effective, involves no ionizing radiation, ficities greater than 0.90 in the diagnosis of
and generally does not require sedation. Nu- biliary atresia, but accurately identifying an
merous ultrasound characteristics have been abnormal gallbladder remains a subjective

task, particularly for inexperienced operators
[10, 15, 18]. The triangular cord sign, which
is defined as a triangular or tubular echogen-
ic density in the vicinity of the portal vein on
a transverse or longitudinal ultrasound im-
age, has been described as both sensitive and
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved
specific for the diagnosis of biliary atresia
in multiple publications [10, 11, 15, 21–27].
However, sensitivity varied in those studies
from 0.23 to 1.00.
Absence of a common bile duct (CBD),
enlargement of the hepatic artery (HA), and
the identification of hepatic subcapsular flow
(HSF) have also been considered useful for
diagnosing biliary atresia [10, 11, 16, 28–30].
However, the correct weighting of these ul-
trasound characteristics has not been deter-
mined, to our knowledge.
The purpose of our study was therefore to
systematically review and summarize pub-
lished studies on the diagnostic performance
of the triangular cord sign and gallbladder ab-
normalities on sonography as well as the ab-
sence of a CBD, enlargement of the HA, and
the appearance of HSF to determine whether
infants with jaundice also have biliary atresia.
Materials and Methods
This meta-analytic review was prepared with
reference to the Preferred Reporting Items for
Systematic Reviews and Meta-Analysis of Obser-
vation Studies in Epidemiology recommendations
for study reporting [31, 32]. The protocol for this
review has not been published elsewhere.
Search Strategy
We searched MEDLINE and the Web of Sci-
ence databases for English-language articles pub-
lished from January 1990 to May 2015, with key-
word indexed search terms of “(triangular cord
OR gallbladder) AND biliary atresia.”
Study Eligibility
An article was considered potentially eligible
if it evaluated ultrasound imaging in neonates or
infants who developed jaundice. Full-text ver-
sions of potentially eligible articles were obtained
for further evaluation. Studies were included if all
of the following inclusion criteria were met: ex-
plicit criteria defining a positive ultrasound imag-
ing result; surgery, biopsy, or both used as a refer-
ence standard for biliary atresia; surgery, biopsy,
clinical follow-up, or some combination thereof
used as a reference standard for the exclusion of
biliary atresia; sufficient data to extract the num-
ber of true-positive, true-negative, false-positive,
and false-negative results; and sufficient data re-
ported for at least 10 cases. Editorials, letters to
W2 AJR:206, May 2016
Zhou et al.
the editor, review articles, case reports, and ani-
mal experiment studies were excluded. The refer-
ence lists of the included studies were manually
searched to identify other potentially eligible ar-
ticles. Two reviewers, who had 5 and 3 years of
experience for pediatric ultrasound independently
evaluated all relevant studies for eligibility crite-
ria. Disagreements in study selection between the
two reviewers were resolved through consensus. If
no consensus could be reached, a third reviewer
who had more than 5 years of experience in data
extraction was consulted.
Data Extraction
We extracted the following data from each
study: study period, department of the first author,
country of origin, study type (prospective or ret-
rospective), and ultrasound probe frequency. Ul-
trasound characteristics included sample size, sex
ratio, age range, cystic biliary atresia (a subtype
of biliary atresia with portal cysts [20]) included
or not, fasting time before ultrasound examina-
tion, reference standard characteristics, and num-
ber of true-positive, true-negative, false-positive,
and false-negative findings. Detailed ultrasound
features of biliary atresia were also extracted, in-
cluding the location and definition of positive tri-
angular cord thickness, the criteria for an abnor-
mal gallbladder, absence of a CBD, enlargement
of the HA, and the appearance of HSF. The crite-
ria for an abnormal gallbladder were absence of
a gallbladder; small gallbladder, such as length <
1.5 cm; abnormal gallbladder wall or shape; and
no contraction of the gallbladder after feeding.
Methodologic Quality Assessment
The quality of the studies was assessed using
version 2 of the Quality Assessment of Diagnos-
tic Test Accuracy Studies (QUADAS-2) tool [33].
QUADAS-2 examines seven items on the repre-
sentativeness of patient spectrum, selection crite-
ria, reference standard, verification bias, timing,
and study withdrawals. Both reviewers scored the
tool independently and disagreements were re-
solved face to face by consensus.
Statistical Analysis
We extracted or reconstructed 2 × 2 contingen-
cy tables for all of the ultrasound characteristics
reported in each of the included studies. If the in-
cluded studies counted more than one type of gall-
bladder abnormality in the diagnosis of biliary
atresia, only the most used and most accurate type
was used for calculating the general summary
ROC of abnormalities of the gallbladder. If diag-
nostic accuracy was compared between different
groups of observers, only one contingency table
for findings by radiologists was included. Sensitiv-
ity and specificity estimates were calculated from
the extracted contingency tables. Individual study
estimates were plotted in an ROC space to high-
light covariation between sensitivity and specific-
ity and to explore study heterogeneity. A bivariate
mixed-effects regression model was used to calcu-
late summary estimates of accuracy. Heterogene-
ity was quantified with the I2 test statistic includ-
ing 95% CIs, with higher percentages indicating
greater heterogeneity. The risk of reporting bias
was judged from funnel plots. Risk of publication
bias was tested by a regression of the diagnostic
odds ratio against the inverse of the square root of
the effective sample size (ESS). Weighting by ESS
indicated significant asymmetry, with p < 0.05 for
the slope coefficient [34].
We performed subgroup analyses to identify
factors that influence diagnostic accuracy if four
or more studies evaluated with the same modal-
ity were included. We also performed a subgroup
analysis of studies according to the period in
which studies were performed.
All statistical analyses were performed with
Stata software version 11.0 (StataCorp) and Excel
version 14.4 (Microsoft). A two-sided p value <
0.05 was considered to indicate a statistically sig-
nificant difference.
Results
Study and Design Characteristics
Our search identified a total of 419 unique
references, of which 59 were deemed poten-
tially relevant on the basis of title or abstract.
Thirty-six of the 59 relevant articles were ex-
cluded (24 articles that did not satisfy eligi-
bility or methods criteria, six case reports,
four articles in languages other than English,
and two letters to the editor). Thus, 23 arti-
cles fulfilled all inclusion criteria and were
selected for data extraction and analysis [10,
11, 15, 16, 18, 19, 21, 22, 24, 25, 27, 29, 30,
35–44] (Fig. 1).
Individual study characteristics are pre-
sented in Table 1. Eleven studies were re-
ported as prospective, 11 were reported as
retrospective, and one did not specify type of
study. Table S1 summarizes the patient char-
acteristics and criteria for triangular cord
thickness and an abnormal gallbladder in-
cluded in the studies.
In Table 2, we present the risk of bias and
the concerns regarding the applicability of
the studies included. Twenty-one primary
studies were of high quality, obtaining low
risk for six to seven items in the QUADAS
checklist. Two of 23 studies were of lower
quality, obtaining low risk for five items in
the QUADAS checklist. The assessment of
 Ultrasound for the Diagnosis of Biliary Atresia

TABLE 1: Characteristics of Included Studies

First Author and First Author’s Prospective Probe
Reference No. Year Country Department Design Frequencya US Features Study Period
Ikeda [44] 1998 Japan Surgery NR 5.0 GBA 1986–1996
Lee [40] 2000 Taiwan Nuclear medicine No 5.0–7.5 GBA 1989–1999
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved

Tan-Kendrick [41] 2000 Singapore Diagnostic imaging Yes 5.0–10.0 TC, GBA 1997–1999
Kotb [24] 2001 Egypt Pediatrics and radiology Yes 7.0 TC, GBA NR
Farrant [18] 2001 UK Radiology Yes 13.0 GBA 1999–2000
Park [39] 2001 Korea Pediatric surgery No 7.0 TC, TC + GBA 1992–2000
Kanegawa [21] 2003 Japan Radiology Yes 5.0–8.2 TC, GBA 1996–2002
Lee [25] 2003 Korea Diagnostic radiology No 6.0–15.0 TC 1998–2001
Tan-Kendrick [15] 2003 Singapore Diagnostic imaging Yes 5.0–12.0 TC, GBA 1997–2002
Visrutaratna [38] 2003 Thailand Radiology No 7.0–10.0 TC, GBA, TC + GBA 1999–2002
Humphrey [10] 2007 UK Radiology Yes 7.5–13.5 TC, GBA, CBD absence 2002–2005
Kim [16] 2007 Korea Radiology Yes 5.0–10.0 TC, CBD absence, HA > 1.5 cm, 1999–2005
HA:PV ratio > 0.45
Takamizawa [22] 2007 Japan Surgery No 5.0–8.2 TC, GBA 1996–2006
Lee [11] 2009 Korea Radiology No 5.0–12.0 TC, GBA, HSF 2003–2007
Donia [37] 2010 Egypt Pediatrics No 3.0–5.0 TC, GBA 2008–2009
Imanieh [27] 2010 Iran Pediatric gastroenterology No 7.0 TC 2004–2008
Mittal [29] 2011 India Radiologic diagnosis and Yes 3.0–12.0 TC, GBA, CBD absence, HA > 1.5 NR
imaging cm, HA:PV ratio > 0.45, TC +
GBA
Aziz [19] 2011 USA Radiology and biomedical No 4.0–8.0 TC, GBA 2004–2009
imaging
Sun [36] 2011 China Ultrasound No 6.0–10 TC, GBA, TC + GBA 2004–2009
El-Guindi [30] 2013 Egypt Pediatric hepatology Yes 2.0–8.0 TC, GBA, HA > 2.05 mm, HSF 2009–2011
El-Guindi [35] 2014 Egypt Pediatric hepatology Yes 2.0–8.0 TC, GBA, HA > 2.05 mm, HSF, 2011–2013
HA:PV ratio > 0.445
Hanquinet [42] 2015 Switzerland Pediatric radiology No 8.0–14.0 TC, GBA NR
Zhou [43] 2015 China Medical ultrasound Yes ≥ 10 TC, GBA, HA > 1.9 cm, GB 2009–2014
classification, TC + GB
classification
Note: NR = not reported, GBA = gallbladder abnormality, TC = triangular cord sign, TC + GBA = TC and GBA combined, HA = hepatic artery diameter, RHA = right hepatic
artery, HSF = hepatic subcapsular flow, PV = portal vein diameter, CBD = common bile duct.
aReported in megahertz.

potential publication bias displayed asymme-
try in the funnel plot, indicating no publica-
tion bias (p = 0.29).
Overall Diagnostic Accuracy
Table 3 gives the outcomes of the meta-
analysis of the different ultrasound charac-
teristics used for diagnosis of biliary atresia.
Twenty studies used gallbladder abnor-
malities for diagnosis [10, 11, 15, 18, 19, 21,
22, 24, 29, 30, 35–44]. One study combined
abnormalities with the triangular cord sign,
so we could not extract valid data for analysis
[39]. Meta-analysis of the remaining 19 stud-
ies yielded summary sensitivity of 0.85 (95%
CI, 0.76–0.91), summary specificity of 0.92
(95% CI, 0.81–0.97) (Fig. 2A), and the area
under the summary ROC curve (AUC) of
0.94 (95% CI, 0.91–0.95) for the detection of
biliary atresia (Fig. 2B). The between-study
heterogeneity was high for both sensitivity
(I 2 = 94.89%, p < 0.001), and specificity (I 2
= 90.86%, p < 0.001).
Meta-analysis of the 20 studies using a tri-
angular cord sign for diagnosis yielded sum-
mary sensitivity of 0.74 (95% CI, 0.61–0.84),
summary specificity of 0.97 (95% CI, 0.95–
0.99) (Fig. 3A), and AUC of 0.97 (95% CI,
0.95–0.98) for the diagnosis of biliary atresia
[10, 11, 15, 16, 19, 21, 22, 24, 25, 27, 29, 30, 35,
36, 37, 38, 39, 40, 42, 43] (Fig. 3B). The be-
tween-study heterogeneity was high for both
sensitivity (I2 = 93.31%, p < 0.001) and speci-
ficity (I2 = 77.21%, p < 0.001).
Meta-analysis of the five studies that
used a combination of the triangular cord
sign and an abnormal gallbladder for di-
agnosis yielded summary sensitivity of
0.95 (95% CI, 0.70–0.99), summary spec-
ificity of 0.89 (95% CI, 0.79–0.94), and
AUC of 0.94 (95% CI, 0.92–0.96) (Fig.
4A) for the diagnosis of biliary atresia [29,
36, 38, 39, 43].
Meta-analysis of the five studies that used
HA enlargement for diagnosis yielded sum-
mary sensitivity of 0.79 (95% CI, 0.71–0.86),
summary specificity of 0.75 (95% CI, 0.60–
0.86), and AUC of 0.83 (95% CI, 0.80–0.86)

AJR:206, May 2016 W3

 TABLE 2: Patient Selection
Zhou et al.
Risk of Bias Applicability Concerns
Year of Patient Reference Patient Reference
Publication First Author Selection Index Test Standard Flow and Timing Selection Index Test Standard
1998 Ikeda Low Low Low Unclear Low Low Low
2000 Lee Low Low Low Low Low Low Low
2000 Tan-Kendrick Low Low Low High Low Low Low
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved

2001 Kotb Low Low Low Low Low Low Low

2001 Farrant Low Low Low Low Low Low Low
2001 Park Low Low Low Low Low Low Low
2003 Kanegawa Low Low Low High Low Low Low
2003 Lee Low Low Low High Unclear Low Low
2003 Tan-Kendrick Low Low Low High High Low Low
2003 Visrutaratna Low Low Low High Low Low Low
2007 Humphrey Low Low Low Low Low Low Low
2007 Kim Low Low Low Low Low Low Low
2007 Takamizawa Low Low Low Unclear Low Low Low
2009 Lee Low Low Low Low Low Low Low
2010 Donia Low Low Low High Low Low Low
2010 Imanieh Low Low Low High Low Low Low
2011 Mittal Low Low Low Unclear Low Low Low
2011 Aziz Low Low Low Low Low Low Low
2011 Sun Low Low Low Unclear Low Low Low
2013 El-Guindi Low Low Low High Low Low Low
2014 El-Guindi Low Low Low High Low Low Low
2015 Hanquinet Low Low Low Low Low Low Low
2015 Zhou Low Low Low Low Low Low Low

(Fig. 4B) for the diagnosis of biliary atresia normalities and HA enlargement. Although sign and a gallbladder abnormality might in-
[16, 29, 30, 35, 43]. the summary sensitivity of the triangu- crease the combined sensitivity to a higher
lar cord sign is as low as 0.74, the summa- level. Because biliary atresia is a severe dis-
Subgroup Analysis ry specificity of 0.97 is the highest among ease, higher sensitivity will benefit infants
Table 4 sets out the results of the subgroup all ultrasound characteristics. The accuracy who are suspected to have biliary atresia.
analysis of gallbladder abnormalities and the for gallbladder abnormalities (AUC = 0.94) Our review found that an abnormal gall-
triangular cord sign for the diagnosis of bili- is similar to the accuracy for the combina- bladder is the most widely accepted crite-
ary atresia. tion of the triangular cord sign and gallblad- rion for differentiating biliary atresia from
der abnormalities. However, the summary other causes of infantile jaundice. Of 23 eli-
Discussion sensitivity (0.95) of the combination of the gible studies, both gallbladder abnormalities
In our systematic review, we observed that triangular cord sign and gallbladder abnor- and the triangular cord sign were mentioned
the triangular cord sign had the highest diag- malities is superior to that of gallbladder ab- as an ultrasound characteristic in 20 stud-
nostic accuracy for detection of biliary atre- normalities or the triangular cord sign alone. ies, followed by HA enlargement, which was
sia (AUC = 0.97), followed by gallbladder ab- Thus, the combination of the triangular cord mentioned in five studies [16, 29, 35]. The ab-
sence of CBD [10, 29, 30] and HSF was re-
TABLE 3: Outcomes of Meta-Analysis of Different Ultrasound Features in ported in three studies. The least frequent-
Diagnosis of Biliary Atresia
ly mentioned ultrasound characteristics was
Ultrasound No. of HA/portal vein (PV) ratio, which was only
Feature Studies Sensitivity Specificity DOR AUC reported in only two studies [16, 35]. These
GBA 19 0.85 (0.76–0.91) 0.92 (0.81–0.97) 61 (18–204) 0.94 (0.91–0.95) data indicate that abnormalities of the gall-
bladder and the triangular cord sign are the
TC 20 0.74 (0.61–0.84) 0.97 (0.95–0.99) 101 (41–246) 0.97 (0.95–0.98)
most reliable and the most widely used ultra-
TC + GBA 5 0.95 (0.70–0.99) 0.89 (0.79–0.94) 140 (31–637) 0.94 (0.92–0.96) sound characteristics used for the diagnosis
HA enlargement 5 0.79 (0.71–0.86) 0.75 (0.60–0.86) 11 (5–26) 0.83 (0.80–0.86) of biliary atresia. The difficulty in identify-
Note—Values in parentheses are 95% CIs. DOR = diagnostic odds ratio, GBA = gallbladder abnormality, TC = ing the CBD in healthy infants even with a
triangular cord sign, TC + GBA = TC and GBA combined, HA = hepatic artery. high-resolution probe may explain why the

W4 AJR:206, May 2016


TABLE 4: Subgroup Analysis of Gallbladder Abnormality and Triangular Cord Sign
Subgroup No. of Studies
GBA
Absence
Absence or length < 1.5 cm
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved
Wall abnormality
No contractiona
TC
Location
Bifurcation
EARPV
Thickness
≥4 mm
Cutoff value not mentioned
Study periodb
2000 or before
After 2000
Note—Values in parentheses are 95% CIs. DOR = diagnostic odds ratio, EARPV = echogenic anterior wall of the right portal vein.
aNo contraction was defined as a gallbladder that did not contract after feeding.
bStudy period of 2000 or before contains studies with objects initiated in 2000 or before. Study period after 2000 contains studies with all the objects initiated after 2000.
absence of the CBD is not more widely used
for diagnosis. Furthermore, because HSF is
highly dependent on both the operator’s ex-
perience and the scanner condition, differ-
ent operators from different institutions will
have difficulty achieving consistent results.
Although diagnostic performance of gall-
bladder abnormalities was below that of trian-
gular cord thickness, subgroup analysis found
that an absent gallbladder could yield a sum-
mary specificity of 0.99, which is comparable
to that of the triangular cord sign. Further-
more, the diagnostic accuracy of gallblad-
ders with abnormal walls is best among all
types of gallbladder abnormalities. The sub-
group analysis results also indicated the crite-
ria for determining gallbladder abnormalities
varied between studies, which might help ex-
plain discrepancies in the diagnostic accura-
cy of different studies. Correct identification
of different types of abnormal gallbladders
could improve the diagnostic accuracy of ul-
trasound for the detection of biliary atresia.
However, identifying an abnormal gallblad-
der on ultrasound remains a subjective task
[10]. A more objective gallbladder classifica-
tion system that could unify all these crite-
ria may improve the diagnostic accuracy [43].
Subgroup analysis of the triangular cord
sign showed that triangular cords located at
the echogenic anterior wall of the right portal
vein (EARPV) in six studies yielded a sum-
AJR:206, May 2016 W5
Ultrasound for the Diagnosis of Biliary Atresia
Sensitivity Specificity
10 0.28 (0.19–0.40) 0.99 (0.93–1.00)
6 0.79 (0.66–0.88) 0.87 (0.65–0.96)
5 0.83 (0.70–0.91) 0.94 (0.91–0.96)
5 0.89 (0.81–0.93) 0.79 (0.55–0.92)
10 0.80 (0.58–0.92) 0.99 (0.96–1.00)
6 0.63 (0.55–0.71) 0.95 (0.89–0.98)
7 0.60 (0.46–0.72) 0.97 (0.94–0.99)
9 0.74 (0.48–0.90) 0.99 (0.94–1.00)
8 0.87 (0.77–0.93) 0.98 (0.93–1.00)
10 0.58 (0.41–0.73) 0.96 (0.93–0.98)
mary sensitivity of 0.63 (95% CI, 0.55–0.71)
and an AUC of 0.74 (95% CI, 0.70–0.77),
which were lower than the corresponding
values for triangular cords located at the por-
tal vein bifurcation. Moreover, the diagnostic
performance of a triangular cord thickness
of 4 mm or more in seven studies was not as
good as that in studies that did not mention
a cutoff value, which indicates that this char-
acteristic is not a useful diagnostic tool. The
assumption that the triangular cord thick-
ness in infants with early-stage biliary atre-
sia was less than 4 mm might be one explana-
tion for this outcome [45]. Subgroup analysis
also showed that although the summary sen-
sitivities of different types of the triangular
cord sign varied substantially, the specifici-
ties were always high.
Hepatobiliary scintigraphy was an im-
portant diagnostic modality for distinguish-
ing biliary atresia from neonatal hepatitis.
This procedure had summary sensitivity of
0.987, but its summary specificity was as low
as 0.704 [46]. Our meta-analysis showed the
specificity of ultrasound is much better than
that of scintigraphy for the diagnosis of bil-
iary atresia. Several of the included studies
also found that the specificity and accuracy of
ultrasound were better than that for scintig-
raphy [10, 24, 47]. MR cholangiography was
another useful imaging modality for diagnos-
ing or excluding biliary atresia because it per-
DOR AUC
47 (7–340) 0.64 (0.60–0.68)
26 (6–106) 0.86 (0.83–0.89)
82 (30–223) 0.96 (0.94–0.97)
30 (11–79) 0.90 (0.87–0.92)
427 (62–2928) 0.98 (0.97–0.99)
33 (12–87) 0.74 (0.70–0.77)
54 (17–171) 0.94 (0.92–0.96)
288 (23–3583) 0.98 (0.96–0.99)
371 (80–1728) 0.97 (0.95–0.98)
33 (15–76) 0.96 (0.93–0.97)
mits evaluation of the existence of an extrahe-
patic bile duct [47, 48]. The accuracy of MR
cholangiography could be improved with IV
administration of a contrast agent. However,
infants undergoing the procedure require oral
or deep IV sedation [47, 48].
Liver biopsy is recommended for in-
fants in whom noninvasive procedures yield
equivocal results [49]. The diagnostic ac-
curacy of liver biopsy for biliary atresia is
90% or greater [24, 50]. However, when per-
formed early in the course of biliary atre-
sia, biopsy can incorrectly appear to indicate
hepatitis [13, 51]. Studies have shown the di-
agnostic accuracy of ultrasound to be supe-
rior to that of liver biopsy in the diagnosis of
biliary atresia [23, 24].
Most studies included in this meta-analy-
sis used the triangular cord sign as a diagnos-
tic characteristic, and surgery and biopsy were
used as reference standards, with a wide range
of sensitivities (0.23–1.00) and specificities
(0.48–1.00). These differences may be the re-
sult of a number of factors. First, the technical
quality and performance of ultrasound varied
across studies. We included studies conduct-
ed from 1998 to 2014; technologic advances
in ultrasound equipment may explain some of
the variation. However, subgroup analysis ac-
cording to study period showed no difference
between studies performed up to 2000 and
those performed after 2000. Second, the cri-

teria used to define a positive triangular cord
sign differed across studies. Third, the com-
position of patients (i.e., some included cys-
tic biliary atresia and some excluded cystic
biliary atresia) among studies was different.
The prevalence of the triangular cord sign be-
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved
tween cystic biliary atresia and general biliary
atresia may be different [20]. Similar factors
may have also contributed to the variation in
the accuracy of gallbladder abnormalities be-
tween studies.
Finally, considerable heterogeneity in
the sensitivity and specificity values across
studies was observed in our systematic re-
view. The heterogeneity was mainly caused
by variations in study design, patient char-
acteristics, technical aspects of the imaging
modalities, and data reporting. We used a
random-effects meta-analysis to address the
heterogeneous data. Because the 95% CIs
were not wide, we believe that our results are
valid. Nevertheless, heterogeneity in diag-
nostic studies remains a concern and may in-
fluence the certainty of the conclusions.
Conclusion
The triangular cord sign and gallbladder
abnormalities are the two most accurate and
widely accepted ultrasound characteristics
currently used for the diagnosis or exclusion
of biliary atresia. The combination of the
triangular cord sign and gallbladder abnor-
malities can improve diagnostic sensitivity.
The absence of a gallbladder is as specific as
the triangular cord sign in the diagnosis of
biliary atresia. Other ultrasound character-
istics, including the absence of a CBD, en-
largement of the HA, and the appearance of
HSF, are less valuable findings for diagnosis.
A detailed ultrasound examination for the
triangular cord sign and for gallbladder ab-
normalities could reduce the need for liver
biopsies and hepatobiliary scintigraphy for
infants suspected to have biliary atresia.
References
1. Hartley JL, Davenport M, Kelly DA. Biliary atre-
sia. Lancet 2009; 374:1704–1713
2. Yoon PW, Bresee JS, Olney RS, James LM, Khoury
MJ. Epidemiology of biliary atresia: a population-
based study. Pediatrics 1997; 99:376–382
3. Chardot C, Carton M, Spire-Bendelac N, Le Pom-
melet C, Golmard JL, Auvert B. Epidemiology of
biliary atresia in France: a national study 1986-96.
J Hepatol 1999; 31:1006–1013
4. McKiernan PJ, Baker AJ, Kelly DA. The frequen-
cy and outcome of biliary atresia in the UK and
Ireland. Lancet 2000; 355:25–29
W6 AJR:206, May 2016
Zhou et al.
5. Hsiao CH, Chang MH, Chen HL, et al. Universal
screening for biliary atresia using an infant stool col-
or card in Taiwan. Hepatology 2008; 47:1233–1240
6. Sokol RJ, Shepherd RW, Superina R, Bezerra JA,
Robuck P, Hoofnagle JH. Screening and outcomes
in biliary atresia: summary of a National Institutes
of Health workshop. Hepatology 2007; 46:566–581
7. Wildhaber BE, Majno P, Mayr J, et al. Biliary atre-
sia: Swiss national study, 1994-2004. J Pediatr
Gastroenterol Nutr 2008; 46:299–307
8. Serinet MO, Wildhaber BE, Broue P, et al. Impact
of age at Kasai operation on its results in late child-
hood and adolescence: a rational basis for biliary
atresia screening. Pediatrics 2009; 123:1280–1286
9. Kim GC, Choe BH, Lee SY, Ryeom HK. Triangu-
lar cord sign in biliary atresia: does it have prog-
nostic and medicolegal significance? (response to
letter) Radiology 2012; 263:621–622
10. Humphrey TM, Stringer MD. Biliary atresia: US
diagnosis. Radiology 2007; 244:845–851
11. Lee MS, Kim MJ, Lee MJ, et al. Biliary atresia:
color Doppler US findings in neonates and infants.
Radiology 2009; 252:282–289
12. Ikeda S, Sera Y, Akagi M. Serial ultrasonic ex-
amination to differentiate biliary atresia from
neonatal hepatitis: special reference to changes in
size of the gallbladder. Eur J Pediatr 1989;
148:396–400
13. Choi SO, Park WH, Lee HJ, Woo SK. ‘Triangular
cord’: a sonographic finding applicable in the diag-
nosis of biliary atresia. J Pediatr Surg 1996;
31:363–366
14. Farrant P, Meire HB, Mieli-Vergani G. Ultrasound
features of the gall bladder in infants presenting
with conjugated hyperbilirubinaemia. Br J Radiol
2000; 73:1154–1158
15. Tan-Kendrick AP, Phua KB, Ooi BC, Tan CE. Bili-
ary atresia: making the diagnosis by the gallbladder
ghost triad. Pediatr Radiol 2003; 33:311–315
16. Kim WS, Cheon JE, Youn BJ, et al. Hepatic arte-
rial diameter measured with US: adjunct for US
diagnosis of biliary atresia. Radiology 2007;
245:549–555
17. Lee SY, Kim GC, Choe BH, et al. Efficacy of US-
guided percutaneous cholecystocholangiography
for the early exclusion and type determination of
biliary atresia. Radiology 2011; 261:916–922
18. Farrant P, Meire HB, Mieli-Vergani G. Improved
diagnosis of extraheptic biliary atresia by high
frequency ultrasound of the gall bladder. Br J
­Radiol 2001; 74:952–954
19. Aziz S, Wild Y, Rosenthal P, Goldstein RB. Pseu-
do gallbladder sign in biliary atresia: an imaging
pitfall. Pediatr Radiol 2011; 41:620–626
20. Zhou LY, Guan BY, Li L, et al. Objective differential
characteristics of cystic biliary atresia and choledoch-
al cysts in neonates and young infants: sonographic
findings. J Ultrasound Med 2012; 31:833–841
21. Kanegawa K, Akasaka Y, Kitamura E, et al. Sono-
graphic diagnosis of biliary atresia in pediatric
patients using the “triangular cord” sign versus
gallbladder length and contraction. AJR 2003;
181:1387–1390
22. Takamizawa S, Zaima A, Muraji T, et al. Can bili-
ary atresia be diagnosed by ultrasonography
alone? J Pediatr Surg 2007; 42:2093–2096
23. Park WH, Choi SO, Lee HJ, Kim SP, Zeon SK,
Lee SL. A new diagnostic approach to biliary
atresia with emphasis on the ultrasonographic tri-
angular cord sign: comparison of ultrasonogra-
phy, hepatobiliary scintigraphy, and liver needle
biopsy in the evaluation of infantile cholestasis.
J Pediatr Surg 1997; 32:1555–1559
24. Kotb MA, Kotb A, Sheba MF, et al. Evaluation of
the triangular cord sign in the diagnosis of biliary
atresia. Pediatrics 2001; 108:416–420
25. Lee HJ, Lee SM, Park WH, Choi SO. Objective
criteria of triangular cord sign in biliary atresia on
US scans. Radiology 2003; 229:395–400
26. Li SX, Zhang Y, Sun M, et al. Ultrasonic diagnosis
of biliary atresia: a retrospective analysis of 20 pa-
tients. World J Gastroenterol 2008; 14:3579–3582
27. Imanieh MH, Dehghani SM, Bagheri MH, et al.
Triangular cord sign in detection of biliary atresia:
is it a valuable sign? Dig Dis Sci 2010; 55:172–175
28. Azuma T, Nakamura T, Nakahira M, Harumoto
K, Nakaoka T, Moriuchi T. Pre-operative ultraso-
nographic diagnosis of biliary atresia with refer-
ence to the presence or absence of the extrahepatic
bile duct. Pediatr Surg Int 2003; 19:475–477
29. Mittal V, Saxena AK, Sodhi KS, et al. Role of ab-
dominal sonography in the preoperative diagnosis
of extrahepatic biliary atresia in infants younger
than 90 days. AJR 2011; 196:[web]W438–W445
30. El-Guindi MA, Sira MM, Konsowa HA, El-Abd OL,
Salem TA. Value of hepatic subcapsular flow by color
Doppler ultrasonography in the diagnosis of biliary
atresia. J Gastroenterol Hepatol 2013; 28:867–872
31. Stroup DF, Berlin JA, Morton SC. Meta-analysis
of observational studies in epidemiology: a pro-
posal for reporting. JAMA 2000;283:2008–2012
32. Moher D, Liberati A, Tetzlaff J, Altman DG;
PRISMA Group. Preferred reporting items for sys-
tematic reviews and meta-analyses: the ­PRISMA
statement. PLoS Med 2009;6:e1000097
33. Whiting PF, Rutjes AW, Westwood ME, et al.
QUADAS-2: a revised tool for the quality assess-
ment of diagnostic accuracy studies. Ann Intern
Med 2011; 155:529–536
34. Deeks JJ, Macaskill P, Irwig L. The performance of
tests of publication bias and other sample size effects
in systematic reviews of diagnostic test accuracy was
assessed. J Clin Epidemiol 2005; 58:882–893
35. El-Guindi MA, Sira MM, Sira AM, et al. Design
and validation of a diagnostic score for biliary
atresia. J Hepatol 2014; 61:116–123 [Erratum in
 Ultrasound for the Diagnosis of Biliary Atresia
J Hepatol 2015; 63:289]
36. Sun Y, Zheng S, Qian Q. Ultrasonographic evalu-
ation in the differential diagnosis of biliary atresia
and infantile hepatitis syndrome. Pediatr Surg Int
2011; 27:675–679
37. Donia AE, Ibrahim SM, Kader MS, et al. Predic-
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved
tive value of assessment of different modalities in
the diagnosis of infantile cholestasis. J Int Med
Res 2010; 38:2100–2116
38. Visrutaratna P, Wongsawasdi L, Lerttumnongtum
P, Singhavejsakul J, Kattipattanapong V, Ukarapol
N. Triangular cord sign and ultrasound features of
the gall bladder in infants with biliary atresia.
Australas Radiol 2003; 47:252–256
39. Park WH, Choi SO, Lee HJ. Technical innovation
for noninvasive and early diagnosis of biliary atre-
sia: the ultrasonographic “triangular cord” sign.
J Hepatobiliary Pancreat Surg 2001; 8:337–341
40. Lee CH, Wang PW, Lee TT, et al. The significance
of functioning gallbladder visualization on hepa-
tobiliary scintigraphy in infants with persistent
jaundice. J Nucl Med 2000; 41:1209–1213
41. Tan-Kendrick AP, Phua KB, Subramaniam R, Goh
Records identified
through database
searching (n = 419)
Records after
duplicates
removed (n = 257)
Records
screened
(n = 257)
Full-text articles
assessed for
eligibility (n = 59)
Full-text articles
assessed for
eligibility (n = 23)
AJR:206, May 2016 W7
ASW, Ooi BC, Tan CE. Making the diagnosis of
biliary atresia using the triangular cord sign and
gallbladder length. Pediatr Radiol 2000; 30:69–73
42. Hanquinet S, Courvoisier DS, Rougemont AL, et al.
Contribution of acoustic radiation force impulse
(ARFI) elastography to the ultrasound diagnosis of
biliary atresia. Pediatr Radiol 2015; 45:1489–1495
43. Zhou LY, Wang W, Shan QY, et al. Optimizing the
US diagnosis of biliary atresia with a modified
triangular cord thickness and gallbladder classifi-
cation. Radiology 2015; 277:181–191
44. Ikeda S, Sera Y, Ohshiro H, Uchino S, Akizuki M,
Kondo Y. Gallbladder contraction in biliary atre-
sia: a pitfall of ultrasound diagnosis. Pediatr
­Radiol 1998; 28:451–453
45. Saxena AK, Mittal V, Sodhi KS. Triangular cord
sign in biliary atresia: does it have prognostic and
medicolegal significance? (letter) Radiology
2012; 263:621
46. Kianifar HR, Tehranian S, Shojaei P, et al. Accu-
racy of hepatobiliary scintigraphy for differentia-
tion of neonatal hepatitis from biliary atresia:
systematic review and meta-analysis of the litera-
Records excluded
by title or abstract
(n = 198)
Full-text
articles excluded
(n = 36; 24 did not
satisfy eligibility
or methods
criteria, 6 case
reports, 4 not in
English, 2 letters)
Fig. 1—Flow diagram of study selection.
ture. Pediatr Radiol 2013; 43:905–919
47. Ryeom HK, Choe BH, Kim JY, et al. Biliary atre-
sia: feasibility of mangafodipir trisodium-en-
hanced MR cholangiography for evaluation.
­Radiology 2005; 235:250–258
48. Kim MJ, Park YN, Han SJ, et al. Biliary atresia in
neonates and infants: triangular area of high sig-
nal intensity in the porta hepatis at T2-weighted
MR cholangiography with US and histopathologic
correlation. Radiology 2000; 215:395–401
49. Moyer V, Freese DK, Whitington PF, et al. Guide-
line for the evaluation of cholestatic jaundice in
infants: recommendations of the North American
Society for Pediatric Gastroenterology, Hepatolo-
gy and Nutrition. J Pediatr Gastroenterol Nutr
2004; 39:115–128
50. Brough AJ, Bernstein J. Conjugated hyperbiliru-
binemia in early infancy: a reassessment of liver.
Hum Pathol 1974; 5:507–516
51. Landing BH, Wells TR, Ramicone E. Time course
of the intrahepatic lesion of extrahepatic biliary
atresia: a morphometric study. Pediatric Pathol
1985; 4:309–319
 Zhou et al.

Study Sensitivity (95% CI) Study Specificity (95% CI)

Hanquinet 2015 0.40 (0.12–0.74) Hanquinet 2015 1.00 (0.69–1.00)

Zhou 2015 0.87 (0.80–0.92) Zhou 2015 0.90 (0.84–0.95)
El-Guindi 2014 0.77 (0.58–0.90) El-Guindi 2014 0.77 (0.59–0.90)
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved

El-Guindi 2013 0.93 (0.76–0.99) El-Guindi 2013 0.48 (0.29–0.68)

Sun 2011 0.36 (0.28–0.44) Sun 2011 0.83 (0.64–0.94)
Mittal 2011 0.83 (0.65–0.94) Mittal 2011 0.83 (0.72–0.91)
Aziz 2011 1.00 (0.78–1.00) Aziz 2011 1.00 (0.83–1.00)
Donia 2010 0.64 (0.44–0.81) Donia 2010 0.82 (0.60–0.95)
Lee 2009 0.66 (0.46–0.82) Lee 2009 0.74 (0.57–0.88)
Takamizawa 2007 0.87 (0.66–0.97) Takamizawa 2007 0.72 (0.55–0.86)
Humphrey 2007 0.70 (0.47–0.87) Humphrey 2007 1.00 (0.94–1.00)
Visrutaratna 2003 0.96 (0.78–1.00) Visrutaratna 2003 0.70 (0.47–0.87)
Tan-Kendrick 2003 0.97 (0.83–1.00) Tan-Kendrick 2003 1.00 (0.98–1.00)
Kanegawa 2003 0.85 (0.55–0.98) Kanegawa 2003 0.73 (0.52–0.88)
Kotb 2001 0.92 (0.74–0.99) Kotb 2001 0.75 (0.59–0.87)
Farrant 2001 0.92 (0.78–0.98) Farrant 2001 0.97 (0.92–0.99)
Lee 2000 0.82 (0.68–0.91) Lee 2000 0.63 (0.53–0.72)
Tan-Kendrick 2000 1.00 (0.74–1.00) Tan-Kendrick 2000 1.00 (0.93–1.00)
Ikeda 1998 0.88 (0.70–0.98) Ikeda 1998 1.00 (0.91–1.00)

All studies 0.85 (0.76–0.91) All studies 0.92 (0.81–0.97)

Q = 352.35, df = 18.00, p = 0.00 Q = 197.04, df = 18.00, p = 0.00
I 2 = 94.89 (93.45–96.33) I 2 = 90.86 (87.79–93.94)

0.1 1.0 0.3 1.0

Sensitivity Specificity

A
Fig. 2—Gallbladder abnormalities for diagnosis.
A, Forest plots of sensitivity and specificity of gallbladder abnormalities for diagnosis. 1.0
B, Summary ROC curve (solid line, AUC = 0.94 [95% CI, 0.91–0.95]) with 95%
prediction contour (dotted line) and confidence contour (dashed line). Black
diamond = summary operating point (sensitivity, 0.85 [95% CI, 0.76–0.91];
specificity, 0.92 [95% CI, 0.81–0.97]); circles = observed data points.
Sensitivity

0.5

0
1.0 0.5 0
Specificity

W8 AJR:206, May 2016

 Ultrasound for the Diagnosis of Biliary Atresia

Study Sensitivity (95% CI) Study Specificity (95% CI)

Zhou 2015 0.92 (0.86–0.96) Zhou 2015 0.94 (0.89–0.98)

Hanquinet 2015 0.70 (0.35–0.93) Hanquinet 2015 0.90 (0.55–1.00)
El-Guindi 2014 0.63 (0.44–0.80) El-Guindi 2014 0.87 (0.69–0.96)
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved

El-Guindi 2013 0.59 (0.39–0.78) El-Guindi 2013 0.89 (0.71–0.98)

Sun 2011 0.27 (0.20–0.35) Sun 2011 0.97 (0.83–1.00)
Aziz 2011 0.60 (0.32–0.84) Aziz 2011 0.95 (0.75–1.00)
Mittal 2011 0.23 (0.10–0.42) Mittal 2011 0.97 (0.90–1.00)
Imanieh 2010 0.70 (0.35–0.93) Imanieh 2010 0.96 (0.86–0.99)
Donia 2010 0.19 (0.06–0.38) Donia 2010 1.00 (0.85–1.00)
Lee 2009 0.62 (0.42–0.79) Lee 2009 1.00 (0.90–1.00)
Takamizawa 2007 0.85 (0.72–0.94) Takamizawa 2007 0.95 (0.82–0.99)
Kim 2007 0.58 (0.41–0.74) Kim 2007 0.93 (0.78–0.99)
Humphrey 2007 0.73 (0.54–0.88) Humphrey 2007 1.00 (0.94–1.00)
Visrutaratna 2003 0.96 (0.78–1.00) Visrutaratna 2003 0.74 (0.52–0.90)
Tan-Kendrick 2003 0.84 (0.66–0.95) Tan-Kendrick 2003 1.00 (0.98–1.00)
Lee 2003 0.80 (0.56–0.94) Lee 2003 0.98 (0.92–1.00)
Kanegawa 2003 0.93 (0.77–0.99) Kanegawa 2003 0.96 (0.80–1.00)
Park 2001 0.83 (0.65–0.94) Park 2001 0.98 (0.91–1.00)
Kotb 2001 1.00 (0.86–1.00) Kotb 2001 1.00 (0.91–1.00)
Tan-Kendrick 2000 0.83 (0.52–0.98) Tan-Kendrick 2000 1.00 (0.93–1.00)

All studies 0.74 (0.61–0.84) All studies 0.97 (0.95–0.99)

Q = 297.87, df = 19.00, p = 0.00 Q = 7937.04, df = 19.00, p = 0.00
I 2 = 93.62 (91.74–95.50) I 2 = 76.06 (87.79–66.36)

0.1 1.0 0.3 1.0

Sensitivity Specificity

A
Fig. 3—Triangular cord sign for diagnosis.
A, Forest plots of sensitivity and specificity. 1.0
B, Summary ROC curve (solid line, AUC = 0.97 [95% CI, 0.95–0.98]) with 95%
prediction contour (dotted line) and confidence contour (dashed line). Black
diamond = summary operating point (sensitivity, 0.74 [95% CI, 0.61–0.84];
specificity, 0.97 [95% CI, 0.95–0.99]); circles = observed data points.
Sensitivity

0.5

0
1.0 0.5 0
Specificity

AJR:206, May 2016 W9

 Zhou et al.

1.0 1.0
Downloaded from www.ajronline.org by Gazi Universitesi on 03/27/16 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved

Sensitivity

Sensitivity
0.5 0.5

0 0
1.0 0.5 0 1.0 0.5 0
Specificity Specificity

A B
Fig. 4—Summary ROC curves (solid lines) with 95% prediction contour (dotted lines) and confidence contour (dashed lines). Circles = observed data points.
A, Triangular cord sign and abnormal gallbladder for diagnosis. AUC is 0.94 (95% CI, 0.92–0.96). Black diamond = summary operating point (sensitivity, 0.95 [95% CI,
0.70–0.99]; specificity, 0.89 [95% CI, 0.79–0.94]).
B, Hepatic artery enlargement for diagnosis. AUC is 0.83 (95% CI, 0.80–0.86). Black diamond = summary operating point (sensitivity, 0.79 [95% CI, 0.71–0.86]; specificity,
0.75 [95% CI, 0.60–0.86]).

F O R YO U R I N F O R M AT I O N
A data supplement for this article can be viewed in the online version of the article at: www.ajronline.org.

W10 AJR:206, May 2016