Effect of Aging on the Adult

Extrahepatic Bile Duct

A Sonographic Study
Gil N. Bachar, MD, Maya Cohen, MD,
Alexander Belenky, MD, PhD, Eli Atar, MD,
Shafir Gideon, MD
Objective. To determine whether the size of the extrahepatic bile duct increases with age in adults.
Methods. We prospectively collected data on 251 patients aged 20 years or older who underwent
abdominal sonography. None of the patients had a history of liver, gallbladder, biliary, or pancreatic
disease or surgery. The extrahepatic bile duct was measured at 3 locations: in the porta hepatis, in the
most distal aspect of the head of the pancreas, and midway between these points. Least squares lin-
ear regression was used to correlate patient age and the size of the extrahepatic bile duct. Results.
There were 126 men and 125 women aged 20 to 94 years (mean SD, 52.5 17.63 years). Twelve
percent of the study population were younger than 30 years, and 12% were older than 80 years. The
mean diameters of the common bile duct in the 3 locations were as follows: proximal, 3.39 1.14 mm;
middle, 3.72 1.28 mm; and distal, 4.28 1.18 mm. The overall mean for all measures was 3.66
1.15 mm. The width of the common bile duct ranged from 1.0 to 8.6 mm. There was a significant
correlation between common bile duct size and age (r = 0.535; P < .001). Mean common bile duct
sizes were 3.128 0.862 mm in the patients younger than 50 years and 4.19 1.15 mm in the
patients older than 50 years (P < .001 by independent t test for equality of means). We have found
that the duct gradually dilated 0.04 mm/y. Conclusions. This study revealed an age-dependent change
in the diameter of the extrahepatic bile duct. We suggest that the upper normal limit of the duct in
elderly persons be set at 8.5 mm. Key words: aging; bile ducts; sonography.
Received May 27, 2003, from the Department of
Radiology, Rabin Medical Center, Petah Tiqva,
Israel; affiliated with the Sackler Faculty of
Medicine, Tel Aviv University, Tel Aviv, Israel.
Manuscript accepted for publication June 5, 2003.
Presented at the 88th Scientific Assembly of the
Radiological Society of North America, Chicago,
Illinois USA, December 16, 2002.
Address correspondence and reprint requests to
Gil N. Bachar, MD, Department of Radiology, Rabin
Medical Center, Beilinson Campus, Petah Tiqva
49100, Israel.
E-mail: drbachar@netvision.net.il.
Abbreviations
CBD, common bile duct
onography is a well-established method for evalua-
tion of the extrahepatic biliary system and serves as
a major tool in the diagnosis of suspected bile duct
obstruction. The generally accepted normal size
range for the extrahepatic bile duct at the level of the
common bile duct (CBD) in the porta hepatis is 2 to
7 mm.
13
However, a few researchers have found that the
CBD diameter undergoes age-dependent variations.
25
In
1984, Wu et al
4
reported that the diameter of the CBD
increases normally by 1 mm every decade. Thereafter,
other sonographic studies established 4 mm as the nor-
mal mean CBD diameter at age 40 years, 5 mm at 50
years, and 8 mm at 80 years.
2,3,5
These findings were
recently challenged by Horrow and associates,
6
who
observed no increase in CBD size with age. The aim of
this study was to determine whether the size of the extra-
hepatic bile duct increases with age in adults.
2003 by the American Institute of Ultrasound in Medicine J Ultrasound Med 22:879882, 2003 0278-4297/03/$3.50
S
Article
Materials and Methods
Patient Data
Between November 2001 and March 2002, we
prospectively collected data on 251 patients aged
20 years or older who underwent abdominal
sonography at our unit by 1 of 2 experienced radi-
ologists (G.N.B. and S.G.). None of the patients had
a history of liver, gallbladder, biliary, or pancreatic
disease or surgery. Patients with cholelithiasis or
any gallbladder or pancreatic abnormality were
excluded. In all cases, levels of serum bilirubin,
alkaline phosphatase, and liver transaminases
were measured before the examination and were
within reference ranges. Patients who were taking
medication that causes relaxation of smooth mus-
cle (e.g., calcium blockers and papaverine
hydrochloride) were excluded from the study.
The sonographic scan was performed after a
fasting state of 6 to 12 hours with an HDI 3000
device (Philips Medical Systems, Bothell, WA)
equipped with a 2- to 4-MHz broadband convex
array transducer. The patients were examined
during deep inspiration in the supine or left later-
al oblique position by a right subcostal approach.
The extrahepatic bile duct was identified at the
level of the portal vein, where the hepatic artery
crosses perpendicularly between them. When
bowel gas obscured a part of the suprapancreatic
segment, we had the patient take several deep
breaths and hold the inspiratory phase. Color
Doppler sonography was used to confirm the
identification of the vascular and ductal anatomy.
The extrahepatic bile duct was measured at 3 loca-
tions: in the porta hepatis, in the most distal
aspect of the head of the pancreas, and midway
between these points. For each location, antero-
posterior measurements from inner border to
inner border were obtained from the longitudinal
images using electronic calipers. Three measure-
ments were taken in the 3 locations for each
patient, and the mean values were calculated.
Statistical Analysis
Values are expressed as mean SD. Least squares
linear regression was used to correlate patient age
and size of the extrahepatic bile duct. The mean of
the 3 measured diameters was used as the depen-
dent variable, and age was used as the indepen-
dent variable. The independent t test and one-way
analysis of variance were used to compare the
mean values between age groups. Type I error =
0.05 and P< .05 were considered significant.
Results
There were 126 men and 125 women aged 20 to
94 years (mean SD, 52.5 17.63 years). Twelve
percent of the study population were younger
than 30 years, and 12% were older than 80 years
(Fig. 1). The mean diameters of the CBD in the 3
locations were as follows: proximal, 3.39 1.14
mm; middle, 3.72 1.28 mm; and distal, 4.28
1.18 mm. The overall mean for all measures was
3.66 1.15 mm. The width of the CBD ranged
from 1.0 to 8.6 mm. None of the patients had
widening of the intrahepatic bile ducts. There
was a significant correlation between CBD size
and age (r = 0.535; P< .001; Fig. 2; r
2
= 0.28, which
means that 28% of the variation of CBD can be
explained by age). The mean CBD sizes were 3.13
0.862 mm in the patients younger than 50 years
and 4.19 1.15 mm in the patients older than
50 years (P< .001 by independent t test for equal-
ity of means). Table 1 lists the means, SDs, and
ranges of the duct dimensions in the 7 age
groups. We have found that the duct gradually
dilated 0.04 mm/y.
Discussion
A study by Wu et al
4
in 1984 established the effect
of age on the size of the extrahepatic bile duct.
The study consisted of 256 patients without bil-
iary, pancreatic, or hepatic disease. However,
there were 18 subjects younger than 21 years,
only 10 subjects older than 70 years, and none
older than 90 years. The sizes of the extrahepatic
bile ducts ranged from 1 to 10 mm and were age
dependent (r = 0.60; P < .001). By contrast,
Horrow et al,
6
in a prospective study of 258
patients, failed to observe any increase in CBD
880 J Ultrasound Med 22:879882, 2003
Aging and Common Bile Duct
Figure 1. Patients in the 7 age groups.
size with age. They measured maximal antero-
posterior and transverse diameters of the extra-
hepatic bile duct in the same 3 locations used
here. The overall mean for all measures was 3.5
1.2 mm, with a range of 1.7 to 6.0 mm. The least
squares regression slope was 0.000578
0.000334 mm/y, which differs significantly from
the null hypothesis of 0.1 mm/y (P < .001)
described by Wu et al.
4
However, the study by
Horrow et al
6
had several major limitations. First,
about half the subjects were 45 to 60 years of age,
and age was not uniformly distributed across the
samples, so that too little weight may have been
accorded the very young and the very old. It is
possible that the inclusion of larger numbers of
younger and older patients would have yielded a
statistically significant correlation between age
and size of the bile duct. Moreover, in these other
studies and also in ours, all measurements were
done by only 1 or 2 observers, whereas Horrow et
al
6
used 3 radiologists and 6 sonographers, lead-
ing to a possible interobserver bias. Third, the
patients included in the study were only asked
about previous biliary or pancreatic disease, but
laboratory parameters, such as serum bilirubin,
alkaline phosphatase, and liver transaminase
levels, were not measured before the examina-
tion. Thus, some of the patients might have had
cholelithiasis or choledocholithiasis. In our
study, as in that of Kaim et al,
5
laboratory param-
eters were measured at most 3 days before sono-
graphic imaging.
We found a significant correlation between
CBD size and age (r = 0.535; P < .001; r
2
= 0.28,
which means that 28% of the variation of CBD
can be explained by age). These results are very
close to the results of Wu et al.
4
We found a sig-
nificant difference between the groups younger
than 50 and older than 51 years: 3.13 0.86 ver-
sus 4.19 1.15 mm (P < .001). Moreover, accord-
ing to the mean diameter of the duct in every
decade (Fig. 2), we found that the duct gradually
dilated 0.04 mm/y.
These results are consistent with those from a
study by Kaude
7
in 350 healthy subjects aged 20
to 71 years; they reported CBD size from 2.8 to
4.1 mm. Kaim et al
5
studied an elderly sample of
45 patients older than 75 years; the mean CBD
diameter was 6.2 2.3 mm, with a range of 2.1 to
15.0 mm, which was considerably wider then the
recommended borderline values in the ultra-
sound literature. Perret et al
3
evaluated the CBD
diameter in 1018 healthy subjects aged 60 to 96
years and again found a small albeit statistically
significant increase from 60 years and younger
(3.6 0.2 mm) to 85 years and older (4.0 0.2
mm) (P < .009). In a retrospective study using
stepwise discriminate analysis of cholangio-
grams obtained by endoscopic retrograde
cholangiopancreatography in 165 subjects,
Barthet et al
8
noted a significant correlation of
biliary duct diameter with age (r = 0.27; P = .001).
The enlargement of the bile ducts in elderly
subjects may be explained by the characteristic
fragmentation of the longitudinal smooth myo-
cyte bands and interspersed connective tissue
combined with the decrease in the reticular-elas-
tic framework of the duct wall over time,
9
which
leads to reduced contractility and hypotonus of
the CBD. Moreover, drugs such as calcium antag-
onists and nitroglycerine, which are frequently
taken by the elderly population, may influence
J Ultrasound Med 22:879882, 2003 881
Bachar et al
Figure 2. Average CBD diameter versus age (n = 251).
Table 1. Means, SDs, and Ranges of CBD Diameter
in the 7 Age Groups
CBD Diameter, mm
Age, y Mean SD Range
2030 2.735 0.735 1.24.9
3140 3.033 0.808 1.54.8
4150 3.476 0.834 2.15.3
5160 3.648 0.838 2.16.8
6170 4.069 1.092 2.18.3
7180 4.265 1.008 2.16.5
81 5.033 1.103 3.97.1
P < .0001.
the contractility and tonus of the duct wall. These
differences may explain the considerable varia-
tions reported for the upper limit of the normal
CBD diameter, namely 4, 6, and 7 mm.
2,46,10,11
These inconsistent findings may have been due
to the different inclusion criteria and patient
selection in these studies. Moreover, measure-
ments in the early reports
5,7
were taken in differ-
ent locations along the CBD. We measured the
bile duct at the same locations used by Horrow et
al
6
and Wu et al
4
: the porta hepatis, the most dis-
tal aspect of the head of the pancreas, and mid-
way between the two. For each location,
anteroposterior measurements were obtained
from the longitudinal images and were made
from inner border to inner border with electronic
calipers. Our study shows that the width of the
CBD differs greatly among the 3 locations, with
mean SD values of 3.39 1.14 mm proximally,
3.72 1.28 mm at the middle, and 4.28 1.18 mm
distally. Thus, the CBD gradually widens from the
porta hepatis to the head of the pancreas.
Moreover, in the 10 subjects aged 48 to 85 years,
ectasia was noted in the middle of the duct, and
there was a difference of up to 4.2 mm between
the thinnest and widest parts of the duct within
the same patient. Thus, it is difficult to set a nor-
mal upper limit for the elderly population.
Although Wu et al
4
suggested that the normal
upper limit for the elderly should be set at 10 mm,
only a relatively small number of their patients
(29 of 258) were older than 60 years. Kaim et al,
5
who limited their sample to patients older than 75
years, reported a mean width of 6.5 2.5 mm and
a range of 2.1 to 15.0 mm, both values consider-
ably higher than reported by others.
26
Parulekar
11
studied 73 patients between the
ages of 20 and 65 years who were fasting and had
no evidence of biliary or pancreatic disease. The
upper limit of the CBD was 7.0 mm, and the
mean was 4.1 mm. Bowie
2
suggested that the
upper limit of the normal CBD should be consid-
ered 7 mm. Our results confirm that there is a
considerable increase in the CBD diameter in
elderly subjects in comparison with younger
populations. However, our group included 2
patients aged 85 and 86 years with a CBD diame-
ter of 8.5 mm and 1 patient aged 66 years with a
diameter of 8.6 mm and no enlargement of the
intrahepatic bile ducts, no evidence of cholelithi-
asis, and normal laboratory parameters. We sug-
gest that 8.5 mm be considered the upper limit of
the normal CBD in elderly patients.
In conclusion, this study showed an age-
dependent change in the diameter of the extra-
hepatic bile duct. We suggest that the upper
normal limit of the duct in the elderly should be
set at 8.5 mm.
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