Ultrasound of Bile Ducts—An Update on Measurements, Reference Values, and Their Influencing Factors
Abstract
:1. Introduction
2. Review of the Literature
2.1. Search Strategy
2.2. Study Selection
2.3. Data Extraction
2.4. Summary of the Literature Published Before 2010
2.5. CBD Diameter—Summary of the More Recently Published Literature Since 2010
3. Indications
4. Examination Technique
4.1. Prerequisites for Measurement (e.g., Transducer Type and Frequency, Position of the Patient)
4.1.1. Patient Preparation
- None.
4.1.2. Patient Position (Compare Figure 2a–f)
- Supine position (standard option).
- 15–30° left lateral oblique position (best option).
- Seated or standing position.
4.1.3. Transducer Type and Initial Position (Compare Figure 2a–f)
- Standard abdomen 2–7 MHz multifrequency curvilinear probe, positioned subcostally in the shoulder–navel orientation.
4.2. Method and Technique of Measurements
4.2.1. Extrahepatic Bile Duct (EHD)
- Diameter measurements are conducted at the maximum anteroposterior diameter from the inner-to-inner wall, perpendicular to the course of the duct in longitudinal views and variable deep inhalation at the porta hepatis (proximal), at its most distal aspect close to the head of the pancreas (distal), and midway between these points (middle) (Table 1). Due to the oval cross-section of the bile duct, the anteroposterior diameter is often smaller than the transverse diameter.
- The wall thickness of EHD is measured at the mid-duct as the distance between the inner and outer edge of the internal hypoechoic layer. When the wall thickness is asymmetric, measurements are obtained at the thickest points ([33,34] for EUS). Additionally, the ratio of EHD wall thickness to diameter can be estimated [35].
4.2.2. Intrahepatic Bile Ducts (IHBDs)
5. Reference Values and Influencing Factors
5.1. EHD Diameter
5.1.1. Age as an Influencing Factor
5.1.2. History of Cholecystectomy as an Influencing Factor
5.1.3. History of (Bariatric) Surgery
5.1.4. Sex as a Possible Influencing Factor
5.1.5. Ethnicity as a Possible Influencing Factor
5.1.6. Physiological Factors and Comorbidities
5.1.7. Drugs as Influencing Factors
5.1.8. Influence of Imaging Methods on Measured EHD Diameter
5.2. EHD Wall Thickness
Influencing Factors on EHD Wall Thickness
5.3. Diameters of Intrahepatic Bile Ducts (IHBDs)
Influencing Factors on IHBD Diameters: Imaging Method and History of Cholecystectomy
6. Reference Values and Documentation
7. Practical Tips, Tricks, and Recommendations
- -
- Low: unremarkable liver and cholestasis parameters and unspecific complaints;
- -
- Moderate: unspecific right-sided upper abdominal symptoms and laboratory parameters, which may also be related to exogenous noxious agents and/or steatosis hepatis;
- -
- High: typical right-sided upper abdominal pain, typical elevated liver and cholestasis parameters.
7.1. How to Deal with Aerobilia and Biliodigestive Anastomosis
7.2. Variations
Congenital Bile Duct Malformations
8. Controversies
8.1. Should We Always Image the Cystic Duct During Measurements of the Extrahepatic Bile Duct?
8.2. Is It Necessary to Measure the Extrahepatic Bile Duct in All Parts?
8.3. How Often Can the Papilla Be Visualized?
9. Future Perspectives
10. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Anatomical Structure | What Should I Do? |
---|---|
Extrahepatic bile ducts | Complete visualization of the bile duct from the hepatic bifurcation to the junction with the duodenum. Locate distal CBD in transverse section within the pancreatic head (mimicking a pancreatic cyst due to transversal plane). Turn into the longitudinal course of the CBD by rotating into the right oblique (shoulder–navel section) subcostal position and follow it to the liver hilus, and if possible distally to the duodenum. Visualization of the CHD at the liver hilus with intercostal alignment of the probe. Explanation: the shape of the duct is important, i.e., carry out complete, or only spindle-shaped dilatation over the whole length as normal variation, or due to the confluence of the cystic duct.
|
Intrahepatic bile ducts | Look for the presence of segmental bile duct branches in the liver segments parallel to the portal branches and segmental arteries. If yes—is it segmental congestion or congestion affecting the whole liver? In case of liver cirrhosis—is it really the bile ducts or compensatory enhanced segmental arteries (Color Doppler Imaging)? |
Factors Influencing Increase in EHD Diameter | Correlation/Evidence |
---|---|
Age | ++ |
History of cholecystectomy | ++ |
Inhalation | + |
Periampullary diverticula | + |
History of (bariatric) surgery | + |
Autosomal dominant polycystic kidney disease | + |
Graft-versus-host disease | + |
Opioid or methadone treatment | + |
Female sex | (+) |
Anesthetic drugs (propofol, fentanyl, sufentanyl) | − |
Ethnicity | − |
Imaging Modality | N (Female/Male) | Mean Age (SD) | EHD (mm) | Study Details | Reference |
---|---|---|---|---|---|
Laparoscopic US (LUS) | 253 (167/86) | 43.5 | LUS: 3.7 mm TAUS: 4.0 mm | Obese patients, mean BMI 48, LUS vs. TAUS | Kothari et al. (2013) [46], USA |
MRI | 76 (35/41) | 43.9 | TAUS: 3.17 mm MR: n.s.: 3.14–3.30 mm depending on used sequence | Randomized controlled trial, small n.s. increase with age (0.0155 mm per year) | Prpic et al. (2007) [11], Croatia |
ERC | 50 (39/11) | 58 | TAUS all: 7.9 ± 3.3 mm ERC all: 13.1 ± 4.5 mm TAUS normal: 6.2 ± 2.5 mm ERC normal: 11.5 ± 4.0 mm (significant) | TAUS 2–3 h prior to ERC, all patients post CCE and symptomatic Normal subgroup n = 22 without biliary pathology | O’Connor et al. (1985) [57], GB |
CT | 353 | 59.7 (18.0) | Mean difference US vs. CT—0.27 mm for dilated EHD | Imaging for suspected acute cholecystitis | Schuster et al. (2023) [59], USA |
MRCP/CT/EUS | 109 (74/35) | 71 (14.0) | 10.3–11.0 mm, n.s. | EUS for work up of dilated EHD, retrospective, different clinics | Ferreira et al. (2024) [60], Portugal |
N (Female/Male) | Mean Age (SD) | Imaging Modality | Wall (mm, SD) | Study Background | Reference |
---|---|---|---|---|---|
50 (29/21) | 56.9 y (16.3) | Transduodenal EUS | Controls: 0.8 mm (0.4) PSC: 2.5 mm (0.8) Cut-off: >1.5 mm | British, PSC diagnostic | Mesenas et al. (2006) [35] |
95 (n.a.) | 63.3 y | Intraductal US | Controls: 0.6 mm (0.3) | Japanese, retrospective | Tamada et al. (1999) [33] |
60 (29/31) | 55 y | Radial EUS | Controls (cholestasis): 1.1 mm (0.5) Cut-off: >1.5 mm | Turkey, prospective, cholestasis vs. cholangitis | Alper et al. (2011) [61] |
21 (13/8) | 59 y (29–79) | Linear EUS | Controls: 0.39 ± 0.14 mm PSC: 0.89 ± 0.59 mm | Croatian, prospective, elastography for PSC | Rustemovic 2010 [62] |
Indication | Anatomical Structure |
---|---|
Routine |
|
With clinical question |
|
(A): Non-dilated common bile duct: EHD < 7 mm. | |||
Transabdominally visible in all parts (bifurcation, hilus, retro pancreatic) | |||
Low probability | Moderate probability | High probability | |
Stop biliary diagnostic | W&W possible Consider further diagnostics (MRCP or EUS depending on availability) | Further diagnostics indicated (EUS, MRCP) | |
Transabdominally not visible in all parts (e.g., only in hilus) | |||
Low probability | Moderate probability | High probability | |
W&W Look for other reasons | Further diagnostics indicated (MRCP or EUS depending on availability) | Further diagnostics indicated (EUS > MRCP) | |
(B): Dilated extrahepatic bile duct (EHD): What is normal, what is concerning, and when to clarify further? | |||
What is normal? | What is concerning? | ||
Dilated EHD without symptoms/elevated cholestasis parameters | Dilated EHD with symptoms/elevated cholestasis parameters | ||
No symptoms, no elevated liver or cholestasis parameters, no evidence of outflow obstruction in high quality US | Right-sided upper abdominal pain/colic ± increased liver and cholestasis parameters, other B-symptoms | ||
Known change without symptoms with normal laboratory and normal imaging | Cholecystolithiasis | ||
Simultaneously dilated pancreatic duct > 2.5 mm | |||
Pancreatic cystic lesions/IPMN | |||
Solid lesion of the pancreatic head | |||
Acute/chronic pancreatitis | |||
Increase in dilatation of a presumed benign bile duct dilatation | |||
EHD dilated (e.g., >7 mm) and transabdominally not visible in all parts (e.g., only in hilus) | |||
Low probability | Moderate probability | High probability | |
Consider further diagnostics (MRCP, EUS, including endoscopic assessment of the major papilla with exclusion of a papillary adenoma) | Further diagnostics indicated (EUS, MRCP) | Further diagnostics/therapy indicated | |
EHD dilated (e.g., >7 mm) and transabdominally visible in all parts (bifurcation, hilus, retro pancreatic), preserved respiratory variability, spindle-shaped) | |||
Low probability | Moderate probability | High probability | |
Stop biliary diagnostic | W&W possible Consider further diagnostics (MRCP, or EUS depending on availability, including endoscopic assessment of the major papilla) | Further diagnostics indicated (EUS > MRCP) | |
(C): Visible bile duct stones regardless of EHD diameter | |||
Visible extrahepatic stones regardless of EHD diameter | |||
With symptoms/elevated cholestasis parameters | Without symptoms/without elevated cholestasis parameters | ||
Therapy indicated | Post cholecystectomy | Gallbladder in situ | |
Therapy indicated | W&W (elder patients), consider therapy | ||
Intra hepatic stones regardless of EHD diameter | |||
With symptoms/elevated cholestasis parameters | Without symptoms/elevated cholestasis parameters | ||
Therapy indicated | W&W recommended |
Congenital Changes in the Bile Ducts | ||
---|---|---|
Nature of Changes | Description | Clinical Impact |
Biliary atresia (BA) [77,78] | Obliterative (inflammatory) fibrosing cholangiopathy with obstruction of the intra- and extrahepatic bile ducts. Variations:
Type 1: Atresia of the distal extrahepatic bile duct; Type 2: Atresia of the common bile duct at different levels, presence of a cyst at the hilum; Type 3: Obstruction of the entire extrahepatic biliary system and intrahepatic bile ducts at the hilum; gallbladder, cystic duct, and bile duct may be patent; Type 4: Complete obstruction of all extra- and intrahepatic bile ducts [78]. | Jaundice in the first weeks of life. Association with other severe congenital anomalies. Type 1 and 2 are correctable. Treatment options: Kasai operation, liver transplantation [77]. |
Common bile duct duplication [79] | Presence of a septum within the CBD or an accessory CBD [79]. Not to be confused with the double ductal structure in deep-opening ductus cysticus. | Associated with pancreaticobiliary maljunction and congenital biliary dilatation in children [80]. |
Choledochal cysts (Congenital choledochal malformation) [75,76] | Cystic dilatation of the intra- and extrahepatic bile ducts. On ultrasound: Segmental bile duct dilatation, cystic lesions adjacent to the bile ducts. Classification according to Todani [75,76]: Type I: Cystic or fusiform dilatation of the common duct; right and left hepatic ducts and intrahepatic bile ducts are normal; Type II: Diverticulum of CBD; Type III: Cystic dilatation of distal common bile duct, intramural in the duodenal wall; Type IV: Multiple either intrahepatic or extrahepatic cysts, or exclusively extrahepatic bile ducts; Type V: Single or multiple intrahepatic cysts with normal extrahepatic bile ducts; Caroli disease. | Diagnosis via MRCP, ERCP. Increased prevalence of gallstone formation with subsequent cholangitis and biliary strictures. Increased risk of carcinoma [81]. |
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Lucius, C.; Flückiger, A.; Meier, J.; Möller, K.; Jenssen, C.; Braden, B.; Kallenbach, M.; Misselwitz, B.; Nolsøe, C.; Sienz, M.; et al. Ultrasound of Bile Ducts—An Update on Measurements, Reference Values, and Their Influencing Factors. Diagnostics 2025, 15, 919. https://doi.org/10.3390/diagnostics15070919
Lucius C, Flückiger A, Meier J, Möller K, Jenssen C, Braden B, Kallenbach M, Misselwitz B, Nolsøe C, Sienz M, et al. Ultrasound of Bile Ducts—An Update on Measurements, Reference Values, and Their Influencing Factors. Diagnostics. 2025; 15(7):919. https://doi.org/10.3390/diagnostics15070919
Chicago/Turabian StyleLucius, Claudia, Anja Flückiger, Jennifer Meier, Kathleen Möller, Christian Jenssen, Barbara Braden, Michael Kallenbach, Benjamin Misselwitz, Christian Nolsøe, Michael Sienz, and et al. 2025. "Ultrasound of Bile Ducts—An Update on Measurements, Reference Values, and Their Influencing Factors" Diagnostics 15, no. 7: 919. https://doi.org/10.3390/diagnostics15070919
APA StyleLucius, C., Flückiger, A., Meier, J., Möller, K., Jenssen, C., Braden, B., Kallenbach, M., Misselwitz, B., Nolsøe, C., Sienz, M., Zervides, C., & Dietrich, C. F. (2025). Ultrasound of Bile Ducts—An Update on Measurements, Reference Values, and Their Influencing Factors. Diagnostics, 15(7), 919. https://doi.org/10.3390/diagnostics15070919