Biliary drain

Bile is a yellow-green fluid made by the liver that helps digest fat. It flows through the bile ducts into the small intestine. When a duct is blocked by a tumor, stone or scar, bile backs up. This causes jaundice (yellow skin and eyes), itching, dark urine and pale stools. If the trapped bile gets infected, it can spread to the blood.

A biliary drain is a thin, soft plastic tube that we place through the skin, through the liver and into a bile duct. Doctors call this percutaneous transhepatic biliary drainage, or PTBD. Percutaneous means through the skin, and transhepatic means through the liver. The tube gives bile a way out. See biliary interventions for more on blocked bile ducts.

What we see

For many blockages near the pancreas, ERCP is tried first. A drain through the liver is the standard option when ERCP is not possible or does not work, and for many blockages high in the liver.

See before your procedure and sedation for general steps.

1. 1
   Getting ready

   You lie on your back on the X-ray table. You receive moderate sedation or general anesthesia, antibiotics, and monitors for heart, blood pressure and oxygen.

2. 2
   Mapping the ducts

   We numb the skin on your right side or upper belly. Using ultrasound and X-ray, a very thin needle enters a bile duct, and contrast dye maps the ducts and shows the blockage. This is the cholangiogram.

3. 3
   Placing the drain

   A guidewire is steered through the duct and, when possible, across the blockage into the intestine. The drain slides over the wire and its tip curls to hold it in place.

4. 4
   Securing it

   The tube is fixed to the skin with a stitch or holder, covered with a dressing and connected to a bag.

The procedure usually takes 30 to 60 minutes but can take longer if the blockage is hard to cross. Sometimes we place an external drain first and cross the blockage a few days later, once the ducts have calmed down. Most people stay in the hospital at least one night.

1. First 24 hours
   Rest in the hospital. The site is sore, and it may hurt to take a deep breath. Pain medicine helps. Bile in the bag may look bloody at first.
2. First few days
   Soreness eases over 2 to 3 days, sometimes up to a week. Itching usually starts to improve.
3. First few weeks
   Yellow skin fades slowly as bilirubin falls. Appetite usually returns.
4. Every day
   Flush the drain if we have told you to, change the dressing, and write down how much drains into the bag.
5. Every 8 to 12 weeks
   Short visit to change the tube over a wire, or sooner if it clogs or leaks.

Most people with a biliary drain flush it once a day to keep it from clogging. Change the dressing daily, or sooner if it is wet. Clean the skin with soap and water and dry it well. Empty the bag through the valve at the bottom and change the bag about every 2 weeks, or sooner if it smells or leaks. You can shower from the first day home. Afterward, dry the area and put on a fresh dressing. Do not soak in a bath or pool.

An external drain can remove a lot of fluid, sometimes more than a quart a day. Drink plenty of fluids, and tell us if you feel dizzy, weak or very thirsty. See managing your drain and home supplies for bags, holders and dressings.

It depends on the cause. After stones are cleared or a scar is stretched open, the drain can often come out in weeks to months. If a tumor causes the blockage, we may place a permanent metal stent so the outside tube can be removed. Some people keep a drain long-term, changed on a schedule.

I am honest with patients that a biliary drain is often more sore than they expect, because it passes near the ribs and moves as you breathe. That usually settles within a few days. My goal from day one is to get you to the smallest, simplest setup, ideally a capped tube or an internal stent with nothing outside at all.

Fabio Komlos, MD, interventional radiologist · About Dr. Fabio Komlos

Biliary drainage is effective, but it carries more risk than many other drains because the liver has a rich blood supply and the bile is often infected. Serious problems happen in roughly 2 to 5 in 100 people.