Transhepatic biliary drainage

Bile is a fluid made by your liver. It helps break down food. Your bile flows through the common bile duct that connects the liver, gallbladder and pancreas to the small intestine. If the bile duct(s) gets blocked, the bile cannot drain normally and gets collected before to the site of the blockage.  

When the bile ducts are blocked, bile cannot leave the body and builds up. This build-up produces a yellow colour in the skin called jaundice and can also cause  dark urine, light- or clay-colored stools, itching, nausea, fever and loss of appetite. This condition is potentially serious and needs to be treated. The condition in which bile becomes congested is called cholestasis.

What can cause cholestasis

Several diseases can cause cholestasis including:

• Gallstones (stones in the gallbladder or within the bile ducts)
• Pancreatitis (inflammation of the pancreas)
• Tumors of the bile ducts, pancreas, gallbladder, or liver.
• Cirrhosis (a slowly developing disease in which healthy liver tissue is replaced with scar tissue)
• Hepatitis (inflammation of the liver)
• cholangitis 
• Enlarged lymph nodes in the region of the liver and pancreas
• Postoperative strictures (narrowing of the bile ducts or perforation due to injury to the bile ducts during surgery)
• Perforation 

If your bile duct is blocked, your doctor may recommend that you have a biliary drainage catheter placed. This will allow the bile to drain from your liver. 

Biliary drainage, is traditionally divided into three types: surgical, percutaneous transhepatic, and endoscopic transpapillary drainage.

There are 3 different ways bile can be drained from your liver. Your doctor will discuss these with you before your procedure.

How liver biliary drainage is performed

• An external biliary drainage catheter goes through your skin and into your bile ducts. It will be placed above the blockage. After this procedure you will have a catheter coming out of your body, attached to a drainage bag.

• An internal-external biliary drainage catheter goes through your skin and into your bile ducts, across the blockage. One end of the catheter will sit in your small intestine, and the other will come out of your body and will be attached to a drainage bag. This catheter lets bile flow in 2 directions, either out to the external collecting bag or into your small intestine. This is the most common kind of drainage catheter, but not everyone is able to get this type.

• Internal biliary drainage (stenting) uses a metal cylinder (called a stent) to hold the blocked area open. After this procedure you may have a small catheter coming out of your body. If you have a catheter, you will return to Interventional Radiology later the same day or the following day so your doctor can see if the stent is working well. If it is, the catheter will be removed.

Your drainage catheter or stent will be inserted by an interventional radiologist. 

After the procedure, if you had a drainage catheter placed, it will be attached to a bag to collect the drainage. Your doctor will give you an idea of how much drainage you should expect. 

When biliary drainage should be avoided

Biliary drainage should be avoided if there is:

• Massive ascites (excessive collection of fluid in the abdomen)
• Multiple obstructions within the liver
• Bleeding disorders

Before biliary drainage procedure 

Ask about your medications 

You may need to stop taking some of your medications before your procedure. Talk with your healthcare provider about which medications are safe for you to stop taking. We have included some common examples below. 

– Blood thinners 

– Medications for diabetes 

– Diuretics (water pills) 

Don’t stop taking your medication without talking with your healthcare provider. 

If you’ve had an allergic reaction to contrast dye in the past, tell the doctor doing your biliary drainage catheter procedure. They may tell you to take medication before your procedure. 

On the day of intervention 

• Do not eat anything after midnight the night before your procedure. This includes hard candy and gum. 

• You can drink a total of 400ml (2 glasses) of water between midnight and 2 hours before your scheduled arrival time. Do not drink anything else.

• Bring all of your usual medication(s) (or a complete list) with you.

• If you wear contact lenses, wear your glasses instead, if possible. If you don’t have glasses, please bring a case for your contacts.

• It is also recommended that you bring any recent X-rays or scans with you if you have copies at home.

• A relative or friend must be available to drive you home after the procedure, as you will not be allowed to drive after sedation or anaesthesia.

If you wear any of the following devices on your skin, the manufacturer recommends you remove it before your scan or procedure: 

• Continuous glucose monitor (CGM)
• Insulin pump

Talk with your healthcare provider about scheduling your appointment closer to the date you need to change your device. Make sure you have an extra device with you to put on after your scan or procedure.

If you’re not sure how to manage your glucose while your device is off, talk with the healthcare provider who manages your diabetes care before your appointment. 

What happens during a biliary drainage? 

 This procedure is usually carried out with the assistance of either sedation (medication to relax you) or a general anaesthetic. Intravenous antibiotics are also routinely given before the procedure.

• The patient’s abdomen is cleaned with antiseptic and the skin is numbed with a local anesthetic.
• The doctor inserts a thin needle into the patient’s skin and into a bile duct in the liver.
• The doctor injects a contrast medium (dye) so that the bile ducts and liver can be seen on x-ray.
• The biliary drain is then inserted into the bile duct to allow it to drain.
• The other end of the biliary tube/drain is connected to a bag on the outside of the patient’s abdomen. The bile from the drain will go into the bag. It is therefore normal for this bag to fill up with green-brown bile.

After the biliary drainage procedure

• After your procedure, you will be brought to the recovery room. You will need to stay in bed until the sedation has worn off.

• In the recovery room, your nurse will continue to monitor your pain, heart rate, breathing, and blood pressure. They will monitor your catheter site for any bleeding.
• A biliary drainage procedure is usually an outpatient procedure, which means the patient goes home the same day. Patients are usually observed in the hospital for several hours to make sure there are no unusual side effects from the procedure before they go home.

Here are some other things to take note of after a biliary drainage procedure: 

• You may go back to your normal diet after the procedure.

• You should replace the fluids that are lost through your drainage bag by drinking equal amounts of electrolyte-enriched drinks. Drink at least six to eight glasses of fluid a day while your tube is in place. Your doctor may have other recommendations on how you should replace your fluids.

• Avoid lying or sleeping on the same side as the tube to keep it from twisting.

• You may go back to your normal activities 24 hours after your procedure.

• Do not lift anything heavier than 4kg, unless you are told otherwise.

• Keep taking all of your prescribed medicines after the procedure unless your doctor tells you otherwise.

• You may shower 48 hours after your procedure, but DO NOT swim or soak in water while tube is in place. Take your dressing off before entering the shower.

What are the complications of percutaneous biliary drainage? 

The complications of the procedure may include: 

1. Bile leakage
2. Haemobilia (bleeding from or into the biliary tree)
3. Cholangitis (inflammation of the bile ducts)
4. Haemothorax (collection of blood between the chest wall and the lungs)
5. Pancreatitis
6. Infection

When should I call a doctor after a biliary drainage procedure? 

Watch for the following signs and symptoms after a biliary drainage procedure: 

• Redness, drainage, foul odor, or swelling on the skin around the tube site.
• Pain in the abdomen.
• Nausea or vomiting.
• A change in the color of your stool to a very light or grayish white.
• Shaking chills.
• Temperature above 38°C.
• A yellowing of the skin and eyes.
• Very dark urine.