Biliary Drainage Procedures and Clinical Applications

Definition and Purpose

• Biliary drainage is a medical procedure that involves the decompression of an obstructed biliary system to relieve cholestasis and remove infected bile, which is essential for treating conditions like acute cholangitis and biliary obstruction, as recommended by the American College of Radiology 1, 2
• The procedure aims to decompress the biliary system, drain infected bile, and potentially remove obstructing elements such as stones, according to the American College of Radiology 1, 2

Types of Biliary Drainage

• Endoscopic Retrograde Cholangiopancreatography (ERCP) with stent placement is the first-line procedure for biliary decompression, as recommended by the American College of Radiology 1, 2
• ERCP is considered the safest and most effective method compared to percutaneous or surgical approaches, with lower risk of adverse events and less invasiveness, according to the American College of Radiology 3
• Endoscopic nasobiliary drainage (ENBD) is a procedure that involves the placement of a catheter through the nose into the bile duct, as described in the World Journal of Emergency Surgery 4
• Biliary stent placement is a procedure that involves the insertion of a stent to maintain bile flow, as recommended by the American College of Radiology 1
• Endoscopic sphincterotomy (EST) is a procedure that involves the cutting of the sphincter of Oddi to facilitate bile flow and stone removal, as described in the World Journal of Emergency Surgery 4
• Percutaneous Transhepatic Biliary Drainage (PTBD) is a second-line procedure reserved for patients in whom ERCP fails or is contraindicated, as recommended by the American College of Radiology 1 and the World Journal of Emergency Surgery 4
• EUS-Guided Biliary Drainage (EUS-BD) is a newer alternative technique for biliary drainage when conventional ERCP fails, with technical success rates of 91.5% and clinical success rates of 87%, as reported by the American College of Radiology 1, 2, 3
• Surgical Biliary Drainage is now rarely used due to the widespread availability of less invasive endoscopic and percutaneous techniques, as recommended by the American College of Radiology 1, 2

Clinical Applications and Timing

• In severe acute cholangitis, emergent biliary drainage is essential for survival, as recommended by the World Journal of Emergency Surgery 4
• For moderate (grade 2) acute cholangitis, early decompression (within 24 hours of admission) has been shown to reduce 30-day mortality, as reported by the American College of Radiology 5
• In mild (grade 1) acute cholangitis, patients can initially be observed on medical treatment with antibiotics, as recommended by the American College of Radiology 5
• For malignant biliary obstruction, biliary drainage is preferred over medical management of symptoms as it improves overall quality of life, according to the American College of Radiology 3

Complications of Biliary Drainage

• ERCP-related complications include pancreatitis (3.5%, range 1.6%-15.7%), hemorrhage (1.3%), cholangitis (<1%), stent migration, stent occlusion, perforation, and bile duct injury, as reported by the American College of Radiology 1, 2

Important Considerations

• Injection of contrast under pressure during PTBD should be avoided as it may lead to cholangio-venous reflux and exacerbate septicemia, as recommended by the American College of Radiology 1