Percutaneous biliary drainage

One of the normal functions of the liver is to produce bile.  This drains through a number of small tubes, or ducts, into one larger tube.  This is called the common bile duct.  This then empties into the duodenum, the first part of the bowel after the stomach.  If the bile duct gets blocked, bile cannot drain normally.  This causes jaundice. 

This can be a very serious condition, which needs to be treated.   It used to be necessary to have an open operation to clear the blockage.  Now a fine plastic drainage tube, called a catheter, is put into the duct, through a tiny cut in the skin.  This lets the bile drain externally for a while.  This procedure is called percutaneous, meaning through the skin, biliary drainage.

Once the catheter is in the bile duct, it is usually possible to pass it through the blockage into the duodenum.  This lets the bile drain internally in the normal way.  This may be done separately, one or two days after the first part.  Or, it may be done straight after.  

You have probably had an ultrasound scan or a CT scan, showing that the bile duct is blocked.   The most common causes are gallstones and inflammation around the pancreas.  However, your scan may not have shown the actual cause.  This may only be known once the biliary drainage has been carried out.

It may be possible to clear the blockage by putting a drainage catheter into the bile duct.  This is done by passing a flexible telescope, or endoscope, into the duodenum. 

An operation may still be needed in some cases.  However, in your case it is felt that percutaneous biliary drainage is the most suitable initial treatment.

Your doctors and the radiologist will have discussed your case.  They will feel that this is the best treatment for you.   Your opinion will be taken into account.  If, after discussion with your doctors, you do not want to have this done, you can decide against it.

A specially trained doctor called a radiologist.  Radiologists have special expertise in using imaging equipment, and in interpreting the images produced. They need to look at these images while carrying out the procedure.

• you need to be an inpatient in the hospital.  You will be asked to put on a hospital gown
• you will probably be asked not to eat for four hours before.  You may be told though, that it is alright to drink some water
• You may be given a sedative to relieve anxiety, as well as an antibiotic

You must tell your doctor if - 

• you have any allergies or take any medication to thin your blood such as Aspirin, Warfarin, Heparin, Apixaban or Clopidogrel
• you have ever had a reaction to intravenous contrast medium.  This is the dye used for kidney x-rays and CT scans

The radiologist will keep everything as sterile as possible.  They may wear a theatre gown and operating gloves. 

• you will lie on the x-ray table, usually flat on your back 
• a needle will be put into a vein in your arm.  This will be used to give you a sedative or painkillers.   The needle will not cause any pain  
• you will have a monitoring device attached to your chest and finger
• you will be given oxygen through small tubes in your nose
• your skin will be cleaned with antiseptic.  Most of the rest of your body will be covered with a theatre towel
• the radiologist will decide the most suitable point to put in the drainage catheter.  They will use the x-ray equipment or ultrasound machine to do this .  It is usually put in  between two of your lower ribs, on the right side
• your skin will be anaesthetised with local anaesthetic.  A fine needle will then be put into the liver
• the radiologist will make sure the needle is in a satisfactory position in one of the bile ducts.  A guide wire will then be put through the needle, into the bile duct.  The catheter can then be put in place 
• the procedure may finish at this stage.  The catheter will be fixed to the skin surface, and attached to a drainage bag outside your body
• or, it may be possible to move the wire and catheter through the blockage.  The catheter will then drain the bile into the bowel in the normal way
• a permanent metal tube, called a stent, may be placed across the obstruction.  This will relieve the blockage.  A temporary external catheter may be left in place, attached to a drainage bag

• it may hurt a little, for a very short time.  Any pain you have should be controlled with painkillers
• when the local anaesthetic is injected, it will sting to start with.  This soon passes.  The skin and deeper tissues should then feel numb 
• later, you may feel the needle and then the wire and catheter passing into the liver.  You may feel some discomfort or a dull pushing sensation for a short while at this point
• a nurse, or another member of clinical staff, will stand next to you to look after you.  If you do start to feel pain, they will arrange for you to have more painkillers through the needle in your arm  
• usually, it only takes a short time to put the catheter into the liver.  Once in place it should not hurt at all 

It is different for each patient.  It is not always easy to tell how complex or how straight forward it will be.   It may be over in 45 minutes, but can take longer than 90 minutes. 

As a guide, expect to be in the x-ray department for about an hour and a half.

You will be taken back to your ward on a trolley.  Nurses will take your pulse and blood pressure.  This is to make sure that there are no problems.  You will stay in bed for a few hours, until you have recovered.

You may have an external drainage catheter attached to a bag.  If so, it is important that you try and take care of this.  Try not to move suddenly, for example getting up out of a chair, without remembering about the bag.  Always make sure that it can move freely with you.  However, you will be able to lead a normal life with the catheter. 

The bag needs to be emptied fairly often, so that it does not get too heavy.  The nurses will want to measure the amount in it each time.  Taking an external catheter out does not hurt at all.

These are questions only the doctors looking after you can answer.  It depends, for example, on whether you have a temporary external drainage catheter in place.  Or whether a metal stent has been placed across the blockage. 

You may need further x-rays or scans.  This will be to check the blockage has been cleared, and to try to find the cause.  

Percutaneous biliary drainage is fairly safe.  However, there can be risks and complications, as with any medical treatment.  It is difficult to say exactly how often these happen.  They are usually minor and do not happen very often.

Perhaps the biggest problem is not being able to place the drainage tube satisfactorily.  This is because, even though the duct is blocked, it may not be wide enough for the catheter to be able to pass through.  It is difficult to put a needle into a normal sized bile duct.  If this happens, your doctors will arrange another way to treat the blockage.  This may involve an operation.

Sometimes there is a leak from the duct where the tube has been put in.  This results in a small collection of bile inside the abdomen.  This can cause problems such as discomfort & infection.  Once the catheter is draining bile satisfactorily, the leak should stop.  However, if this becomes a large collection, it may need to be drained.

Patients with jaundice are more likely to have difficulties with blood clotting.  There may therefore be bleeding from the surface of the liver where the catheter is put in.

Rarely patients may need a blood transfusion.   Very rarely, this may be severe, and patients need an operation or another radiology procedure to stop it.

Despite these possible complications, the procedure is normally very safe.  It will almost certainly result in a great improvement in your medical condition.  Very occasionally, an operation is needed.  However, if the percutaneous biliary drainage had not been tried, this operation would have been needed anyway.

This leaflet should have answered some of your questions.  Remember, though, that this is only a starting point for discussion.  Make sure you are satisfied you have had enough information before you sign the consent form.

If you have any questions, you will be able to discuss these with the radiologist before the procedure.   If you have any other medical questions, you should discuss these with your doctor.

If you have specific concerns which you feel you must discuss before your appointment please telephone Radiology office (01896 826417).  Ask to arrange to speak to a consultant radiologist who will be performing your procedure. This may involve planning a time when you are both free to speak.