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Introduction Transabdominal ultrasound (US) is the modality of choice for the initial investigation of patients with suspected biliary disease. There are multiple factors that can affect the quality of an US examination including – operator experience, patient habitus and bowel gas. This study investigated the performance of US in determining the cause of biliary dilation and correlated US findings with definitive diagnoses from other modalities and procedures. Methods One hundred patients were retrospectively identified with an US‐reported common bile duct diameter of 8 mm or greater. Patient records were used to correlate US findings with ‘gold standard’ diagnostic tests – other imaging modalities with conclusive findings and/or endoscopic procedures or surgery with histology. The performance of US was calculated for the most common pathologies encountered. Results A definitive cause for dilation was identified in 38 patients (n = 38). The US diagnosis was correct in 19 of these patients (50% of cases where a cause was identified). Choledocholithiasis was the most common pathology, with 23 instances identified by US (61% of the cases where an aetiology was found). Malignancy formed the next largest group (four cases). Conclusions For most patients with a US‐reported common bile duct 8 mm or greater, a cause for biliary dilation was not established. Further study and methodological refinements are required to understand the clinical context of the cases with no recorded follow up. Performance of US is concordant with published literature. Distal choledocholithiasis remains a challenging area for US.

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