Biliary Drainage

What is a biliary drain?

A biliary drain is a thin, flexible tube with several small holes along the sides. Healthcare providers use biliary drains when bile (a fluid that helps with digestion) can’t drain well from the bile duct that connects your liver to your small intestine.

If something is blocking this duct, bile can back up into your liver (cholestasis). This can cause jaundice, which can give your skin and the white of your eyes a yellow hue. It can cause widespread itchiness as well.

When there’s a bile duct blockage, a biliary drain helps bile flow from your liver into your small intestine. Depending on the type of biliary tube, it may drain to a bag outside your body.

Types of biliary drainage

There are two main types of biliary drainage:

Percutaneous transhepatic biliary drainage (PTBD)

This type of drainage goes through your skin (percutaneous) in your abdomen, through your liver to your bile duct and then into your duodenum (beginning of your small intestine). The bile then drains through a tube (catheter) and into a bag outside your body and also into your intestine. 

Providers use an imaging procedure called fluoroscopy to see the blocked duct and place the catheter.

Endoscopic biliary drainage (EBD)

During an EBD procedure, a provider uses an endoscope (a medical device with a light on the end) and inserts it into your mouth and down your digestive tract until it reaches your bile duct. They then insert a catheter into the scope and into your blocked bile duct to drain it.

Providers may use ultrasound guidance (endoscopic ultrasound-guided biliary drainage), or they may do it with endoscopic retrograde cholangiopancreatography (ERCP).

The bile drainage can exit your body through a tube out of your nose (endoscopic nasobiliary drainage, or ENBD). Or it can involve internal drainage. With internal drainage, your provider places a stent placed via an endoscope that helps drainage of bile from the liver to the intestine.

Biliary stenting

Depending on the cause of the blockage, your provider may place a permanent stent across the site of the bile duct blockage. They may do this a couple of days after the initial drainage procedure.

Why would I need a biliary drain?

The most common reason for needing a biliary drain is a blockage or narrowing (stricture) of a bile duct. This leads to cholestasis, which is the slowing or stalling of bile flow from your liver.

Several conditions can cause a bile duct blockage and cholestasis, including:

• Pancreatitis (inflammation of your pancreas).
• Pancreatic cancer.
• Cholangiocarcinoma (bile duct cancer).
• Gallbladder cancer.
• Liver cancer.
• Enlarged lymph nodes near your pancreas or liver (typically from cancer).
• Primary sclerosing cholangitis (chronic inflammation in your bile ducts that causes scarring).
• Gallstones in your gallbladder or within a bile duct (choledocholithiasis).
• Certain parasitic infections, like Ascaris lumbricoides, Clonorchis sinensis (Chinese liver fluke) and Fasciola hepatica.
• Injury to bile ducts during surgery.

What happens before a biliary drainage procedure?

Preparation for a biliary drainage procedure depends on many factors, like the type of procedure you’re getting and the reason for it. Follow your healthcare provider’s instructions on steps to take before the procedure. Generally, you should:

• Not eat, drink or smoke for at least six hours before the procedure. Clear liquids like water may be OK (your provider will tell you if and when you need to stop).
• Alert your provider to any allergies, especially prior allergic reactions to intravenous (IV) contrast dyes or anesthesia. If you’re getting a stent, also let them know if you have allergies to medical-grade plastics or metals.
• Give your provider’s office an updated list of medications and supplements you take.
• Talk to your provider about whether to stop taking blood-thinning medications (anticoagulants), such as aspirin and warfarin.
• Tell your provider if you are or could be pregnant.

You won’t be able to drive yourself home after the procedure due to the anesthesia you receive, so you’ll need to make plans to have someone else drive you home after it.

What happens during a biliary drainage procedure?

The steps of a biliary drainage procedure vary based on the type you’re getting and the reason for it. Your healthcare provider will walk you through the steps before the procedure. Let them know if you have any questions or concerns.

Steps of a percutaneous biliary drainage procedure

The general steps of a percutaneous biliary drainage (PTBD) procedure include:

1. Your provider will clean the skin on your abdomen with an antiseptic and then numb the area with a local anesthetic.
2. Your provider will insert a thin needle into your skin and into a bile duct in your liver.
3. They’ll inject a fluoroscopic contrast dye so that they can see your bile ducts and liver on an X-ray.
4. Once your provider locates the blocked duct, they’ll insert the biliary drain into the bile duct to allow it to drain. You’ll likely have a catheter (small tube) sticking out from your skin.
5. Your provider will connect the other end of the biliary tube/drain to a bag outside your abdomen. The bile from the drain will go into the bag. (This bag will need emptying several times a day.)

You may eventually be able to remove the external bag and cap the outward drainage tube. Your provider will let you know if this is a possibility. If so, you’ll need to flush the drain with a small amount of normal saline (sterile medical salt water) daily as instructed.

Endoscopic biliary drainage procedure

There are many ways to perform endoscopic biliary drainage (EBD). And providers use different kinds of imaging guidance depending on your unique situation. The general steps of an endoscopic biliary drainage procedure include:

1. You’ll receive general anesthesia or sedation.
2. A provider will numb your throat with an anesthetic spray.
3. Your provider will insert an endoscope into your mouth and guide it down your esophagus and through your stomach to reach the upper part of your small intestine (duodenum).
4. Your provider will slide a different tube, called a catheter, into the endoscope until it reaches the blocked bile duct.
5. Your provider will drain the blocked duct. If they’re doing internal drainage, they’ll insert a stent. If they’re doing external drainage, they’ll run a tube (catheter) from the bile duct, through your digestive tract and out of your nose. They’ll attach the tube to a bag, which will collect the bile. (This bag will need emptying several times a day.) 

What happens after a biliary drainage procedure?

A biliary drainage procedure is usually an outpatient procedure, which usually means you’ll go home the same day or the next day. Right after the procedure, you’ll go to an observation room where providers will check on you for a few hours to make sure you don’t have any side effects or complications.

If you have a catheter and drainage bag, a nurse will teach you how to care for the catheter at home, like how to empty the bag and change the dressing.

What are the risks and possible complications of biliary drainage?

Both types of biliary drainage procedures have disadvantages and possible complications, including:

• Removing the drainage tube by yourself, whether accidentally or on purpose.
• Dislodgment, twisting or collapse of the drainage tube.
• Discomfort or pain.
• Electrolyte abnormalities (due to loss of bile).
• Infection. Your provider will likely give you prophylactic (preventive) antibiotics at the time of placement of the drain to reduce this risk.
• Bleeding, which may require a blood transfusion.

Other complications related to PTBD include:

• Bile leakage around the catheter inside your body.
• Pneumothorax (collection of air outside and around your lungs).

Early complications of biliary stenting include:

• Infection.
• Bleeding.
• Pancreatitis.

Other complications of biliary stents can include:

• Blockages due to tissue overgrowth around the stent or by sludge.
• Dislodgement or migration (moving) of the stent.

Your healthcare provider will go over these risks and possible complications with you. They’ll let you know what signs and symptoms to look out for after the procedure.

How do I take care of myself after a biliary drainage procedure?

If you have an external drainage tube, your healthcare team will give you specific instructions on how to take care of it at home. Be sure to follow them and ask questions if you’re uncertain about something. Here are some things to take note of after a biliary drainage procedure:

• You should replace the fluids that you lose through your drainage bag by drinking equal amounts of electrolyte-enriched drinks. Your provider will let you know which beverages to use and how often to drink them. 
• Get plenty of rest after the procedure. A responsible adult should stay with you the first night after your procedure in case you need help with anything.
• 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.
• Don’t lift anything heavier than 10 pounds unless your provider tells you otherwise.
• Keep taking all your prescribed medicines after the procedure unless your provider tells you otherwise.
• You may shower 48 hours after your procedure, but DON’T swim or soak in water while the tube is in place.

When should I see my healthcare provider after a biliary drainage procedure?

Call your healthcare provider or seek immediate medical care if you have symptoms of infection, like:

• Increased pain, swelling, warmth or skin discoloration near the drain site.
• Pus or fluid leaking from the drain site.
• Fever.

Also, see your provider if:

• There’s a new or increasing yellow tint to your skin or the whites of your eyes.
• You see a sudden change in the color or smell of the bile drainage.
• The tube is coming loose at the drain site.
• You have new or worse abdominal pain.
• You’re vomiting.
• You can’t pass poop or gas.

A note from Cleveland Clinic

Biliary drains help return a healthy flow of bile. There are multiple approaches to this procedure. Know that your healthcare team will work with you to determine which one is best for you. Don’t hesitate to ask questions or voice any concerns. They’re there to help and guide you.