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. The duct gradually dilated 0.04 mm / y. The upper normal limit of the duct in elderly persons should be set at 8. Mm.
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. The duct gradually dilated 0.04 mm / y. The upper normal limit of the duct in elderly persons should be set at 8. Mm.
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. The duct gradually dilated 0.04 mm / y. The upper normal limit of the duct in elderly persons should be set at 8. Mm.
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. References 1. Laing FC. The gallbladder and bile ducts. In: Rumack C, Wilson S, Charboneau JW, eds. Diagnostic Ultrasound. St Louis, MO: CV Mosby Co; 1998: 175216. 2. Bowie JD. What is the upper limit of normal for the common bile duct on ultrasound: how much do you want it to be? 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