Biliary Drainage

Overview

Healthcare providers use biliary drains to address obstructions in the bile ducts. A biliary drain is a slender and flexible tube with multiple tiny openings along its sides. Healthcare providers utilize biliary drains when there is impaired drainage of bile from the bile duct, which connects the liver to the small intestine.

Cholestasis, for instance, occurs when bile accumulates in the liver due to duct blockage. This can lead to jaundice, characterized by yellowing of the skin and the whites of the eyes, and may also result in generalized itching.

A biliary drainage procedure aids in the passage of bile from the liver to the small intestine when there is a blockage in the bile duct. Various medical conditions may necessitate the use of a biliary drain. The approach to biliary drainage can vary depending on the underlying cause and specific requirements of the case. The configuration of the biliary tube may dictate whether the drained bile is collected in an external bag or managed differently.

Types

Biliary drainage comes in two main types.

• Percutaneous transhepatic biliary drainage (PTBD): This particular type of drainage enters the abdomen through the skin (percutaneously), travels through the liver to the bile duct, and finally enters the duodenum (the first part of the small intestine). After passing through a catheter, the bile flows through a catheter into a bag outside the body and into the intestine.
  Healthcare providers utilize a fluoroscopy to identify the obstructed duct and position the catheter.

• Endoscopic biliary drainage (EBD): An endoscope, a medical instrument with a light on the end, is used by a healthcare provider to perform an (EBD) by inserting it into the patient’s mouth and down the digestive tract to the bile duct. Then, they introduce a catheter through the endoscope and into the obstructed bile duct in order to facilitate drainage.
  Endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasonography-guided biliary drainage are two methods available to be used by healthcare providers.
  Endoscopic nasobiliary drainage, or ENBD, is the process of draining bile from the body via a tube inserted through the nose. Internal drainage is another option. When using internal drainage, a stent is inserted by a healthcare provider using an endoscope to facilitate the flow of bile from the liver into the intestines.

Reasons for undergoing the procedure

A bile duct obstruction or narrowing (stricture) is the most frequent cause why biliary drain is needed. This results in cholestasis, a condition where the flow of bile from your liver slows down or comes to a halt.

Cholestasis and bile duct blockage can result from a number of conditions, such as:

• Pancreatitis or inflammation of the pancreas.
• Cancer (pancreas, gallbladder, liver, or bile duct)
• Enlargement of the lymph nodes around the pancreas or liver.
• Chronic inflammation in the bile duct that causes scarring (primary sclerosing cholangitis)
• Gallstone (in the gallbladder or in the bile duct)
• Bile duct injury during surgery.
• Parasitic infection (Ascaris lumbricoides, Clonorchis sinensis(Chinese liver fluke) and Fasciola hepatica).

Risk

There are risks with both biliary draining methods and possible problems such as:

• Bleeding.
• Infection.
• Accidental removal of the drainage tube.
• A drainage tube that twists, collapses, or becomes dislodged.
• Pain or discomfort.
• Abnormal electrolyte levels (resulting from bile loss).

Additional PTBD-related risks consist of:

• Leakage of bile around the catheter within the body.
• Accumulation of air outside and around the lungs (pneumothorax).

Potential early complications of biliary stenting include:

• Bleeding.
• Infection.
• Pancreatitis.

Additional potential complications associated with biliary stents include:

• Obstructions arising from tissue overgrowth encircling the stent or from sludge.
• Displacement or moving of the stent.

The patient and the healthcare provider will discuss these risks and potential problems. They will advise them on what signs and symptoms to watch out for following the procedure.

Before the procedure

Preparation for a biliary drainage procedure varies based on multiple factors, including the type of the procedure and its intended purpose. As directed by the healthcare provider, observe the pre-procedural instructions.

• For at least six hours prior to the procedure, refrain from food, drink, and tobacco. Water and other clear liquids might be safe to consume; their healthcare provider will advise them when to stop.
• Inform the healthcare provider of any sensitivities, particularly if they have ever experienced an allergic response to anesthesia or intravenous (IV) contrast dyes.
• Inform the healthcare provider of any allergies to medical-grade plastics or metals if they are undergoing a stent placement.
• Provide an updated list of all the medications and supplements they take to the office of the healthcare provider.
• Discuss with the healthcare provider whether they should stop taking anticoagulants, such as aspirin and warfarin, which thin the blood.
• Inform the healthcare provider if the patient is planning or they are pregnant.

The anesthesia that the patient will receive during the surgery will prevent them from driving themselves home, so they will need to arrange for a ride from someone else.

During the procedure

The processes involved in a biliary drainage procedure differ depending on the kind and the underlying cause. The processes leading up to the procedure will be demonstrated by the healthcare provider. Please let them know if the patient have any queries or worries.

• Percutaneous biliary drainage procedure: A percutaneous biliary drainage (PTBD) procedure generally consists of the following steps:
  • After using an antiseptic to clean the abdomen’s skin, the healthcare provider will use a local anesthetic to numb the area.
  • A thin needle will be inserted into a bile duct in their liver through the skin.
  • In order to view the liver and bile ducts on an X-ray, a fluoroscopic contrast dye will be administered.
  • After your healthcare provider identifies the obstructed duct, they will introduce the biliary drain into the bile duct to facilitate drainage. You will probably have a catheter (a small tube) extending outward from your skin.
  • The other end of the biliary tube/drain will be attached to a bag outside of the abdomen by the healthcare provider. The bag will hold the bile that comes out of the drain. (This bag needs to be emptied multiple times daily.)

The patient could finally be able to remove the external bag and cap the outer drainage line. If this is a possibility, the healthcare provider will inform them accordingly. If so, they must follow the instructions and flush the drain once a day with a little amount of normal saline.

• Endoscopic biliary drainage procedure: Endoscopic biliary drainage (EBD) can be done in a number of ways. In addition, numerous types of imaging guidance are used by healthcare providers based on their specific situation. An endoscopic biliary drainage technique generally consists of the following steps:
  • The patient will be sedated or put under general anesthesia.
  • An anesthetic spray will be applied by the healthcare provider to numb the throat.
  • An endoscope will be inserted through the mouth, guided down the esophagus and stomachto the duodenum, the upperportion of the small intestine.
  • A tube known as a catheter will be inserted into the endoscope and pushed until it reaches the clogged bile duct.
  • The clogged duct will be cleared by the healthcare provider. A stent will be inserted if internal drainage is being done. In the case of external drainage, a tube (catheter) will be threaded from the bile duct, passing through your digestive tract, and exiting through your nose. The tube will be attached to a bag that will hold the bile. (Patient will need to empty this bag multiple times a day.)

After the procedure

After undergoing outpatient biliary drainage treatment, patients typically go home either on the same day or the following day. Immediately after the procedure, they will be transferred to an observation room where healthcare professionals will closely monitor them for several hours to ensure there are no complications or adverse effects.

A nurse will provide the patient with detailed instructions on how to properly care for their catheter once they are back home. This guidance will include information on changing the dressing and how to empty the drainage bag.

Outcome

Patients who have an external drainage tube will receive comprehensive instructions from their medical team regarding its care at home. It is essential to diligently follow these instructions and seek clarification by asking questions if any confusion arises. After undergoing a biliary drainage procedure, it is crucial to bear in mind the following important considerations:

• The patient should consume equivalent volumes of electrolyte-enriched beverages to replenish the fluids lost through their drainage bag. They will be informed by the healthcare provider about the appropriate beverages to use and how often to consume them.
• After the surgery, the patient are advised to get a lot of rest.The first night after their surgeryshould be spent with a responsible adult in case they require assistance with anything.
• To prevent the tube from twisting, avoid sleeping or lying on the same side as it is.
• After the treatment, the patient can resume their regular activities 24 hours later.
• Lifting more than ten pounds should be avoided.
• After the surgery,continue taking all prescription medications unless instructed otherwise by the healthcare provider.
• The patient is allowed to take a shower 48 hours after the procedure, but it is important to refrain from swimming or soaking in water while the tube is still in place.

If the patient displays any of the following infection-related symptoms, get in touch with the healthcare provider or get medical attention immediately:

• Fever.
• Severe discomfort, swelling,warmth, or discoloration of the skin around the drain site.
• Fluid or pus leakagefrom the drain site.
• The skin or the whites of the eyes’ yellow tint has changed or increased.

Please, also, consult your healthcare provider if you experience any of the following:

• A recent or worsening yellowish hue in your skin or the whites of your eyes.
• The tube becoming loose at the drainage site.
• Difficulty in passing poop or gas.
• Sudden changes to the bile drainage’s color or scent.
• Sudden or worsening abdominal pain.
• Vomiting