Biliary Drains and Stents During Cancer Care

Bile is a greenish-brown fluid the liver makes to digest fat. It travels down the bile ducts into the small bowel. A biliary stent is a short tube that props a blocked duct open from the inside. A biliary drain is a tube passed through the skin into the liver to carry bile out.

Cancer blocks bile ducts often. Pancreatic cancer at the head of the pancreas, cancer of the bile duct itself, gallbladder cancer, and deposits in nearby lymph nodes can all squeeze a duct shut. Bile then backs up into the blood.

That is obstructive jaundice, and it has a recognizable pattern: yellow skin and yellow whites of the eyes, dark urine, pale and smelly stools that are hard to flush, and itching that can be maddening. Macmillan, which describes that pattern, puts the itch down to a build-up of bile salts in the skin. Left alone, StatPearls notes, obstructive jaundice can cause liver cell damage, biliary cirrhosis and a rising risk of cholangitis, the duct infection that can tip into septic shock.

The emergency here is cholangitis, an infection of the bile ducts behind the blockage. StatPearls puts overall mortality below 10 percent once biliary drainage is done, but at about 50 percent for severe cases that go without prompt treatment. Hours matter.

Call emergency services or go to the emergency department if:

• Your temperature reaches 38.0 °C / 100.4 °F or higher. The CDC uses 100.4 °F and the NCI uses 100.5 °F. Use the lower number.
• You get shaking chills, teeth-chattering and violent, with or without a high reading.
• Pain builds under the right ribs or in the upper belly and will not settle.
• The yellow in your skin or eyes is deepening again over a day or two.
• You become confused, unusually sleepy, dizzy on standing, or faint.
• Your drain suddenly stops draining and any of the above is happening.

Classic cholangitis is fever, right upper belly pain and jaundice together, the Charcot triad. StatPearls puts its sensitivity at 26.4 percent, so all three appear in only about a quarter of cases. Do not wait for the full set. About 90 percent of people have fever and 60 to 70 percent are jaundiced. So a fever at or above the reading listed above is reason enough to seek emergency care when you have a biliary stent or drain, even without pain or yellowing. If confusion or shock join in, that is severe cholangitis, and StatPearls says it needs urgent drainage.

Call the interventional radiology or oncology team the same day if:

• Daily output falls sharply, or the bag stays empty for several hours.
• Bile leaks around the tube and soaks the dressing or your clothes.
• The tube looks longer outside the skin, or the stitch or anchor has come loose.
• The skin at the site is red, hot, swollen, or leaking pus.
• Itching, pale stools or dark urine return after they had improved.
• Bile in the bag turns cloudy, thick or foul-smelling.

ERCP, or endoscopic retrograde cholangiopancreatography, is done through the mouth. A flexible camera reaches the outlet of the bile duct in the bowel, and a stent is pushed up through the blockage. Nothing shows on the outside afterwards. StatPearls says endoscopic drainage is generally preferred over the percutaneous route because of its lower complication rate, and calls ERCP the gold standard for biliary decompression, effective in 94 to 98 percent of cases.

Percutaneous transhepatic biliary drainage is used when the endoscope cannot reach or cannot get through. A needle passes through the skin, into the liver and into a bile duct, and a drainage tube is threaded in.

That percutaneous route gives three arrangements, and you must know which one you have:

• External drain. The tube sits above the blockage and all bile runs into a bag. You lose bile from the gut, so digestion and salt balance need watching.
• Internal-external drain. The tube crosses the blockage, with holes on both sides. It can be capped so that bile drains inward the normal way, and uncapped again if it stops working.
• Internal stent alone. Nothing outside at all.

Plastic stents are cheap and effective, and about 10 French across. They tend to clog with sludge within a few months. Self-expanding metal stents open out against the duct wall and stay clear far longer. Which type you get depends on how long the stent is expected to be needed, and on whether surgery is still on the table. Ask which was used for you and why.

Stents move as well as block. Fully covered metal stents shift out of place in roughly 20 percent of cases, plastic and partly covered ones in about 5 percent, and bare metal ones in about 1 percent. Metal stents can also block from the inside as tumor grows through the mesh.

None of this is a failure of your care. Stents are expected to need attention. Ask at the time of placement what the plan is: whether an exchange is already booked, and who to call when jaundice returns.

• Keep the bag below the level of the drain site. Bile flows downhill.
• Empty it before it is completely full, and record the volume and color each day. The guidance CADTH summarised for biliary drains is to empty the bag before it is completely full, since a heavy bag can pull on the tube. Your own daily figure is what makes a drop obvious.
• Never lift the bag above the insertion site, and never let the tube kink under you in bed.
• Wash your hands before and after touching the tube, bag or dressing.
• Change the dressing on the schedule you were given, and keep the site dry.
• Do not flush, cap, uncap, clamp or reposition the drain unless you have been trained to do that exact task.
• Secure the tube with the anchor or tape you were shown. A snag on a door handle is how most tubes come out.

Bile is a strong irritant. Any leak reddens and breaks down skin quickly, so report it early rather than piling on more gauze.

Success has visible signs. The yellow fades from the whites of the eyes first. Urine lightens. Stools regain their color. The itch eases over days. Blood tests show falling bilirubin.

If those improvements go into reverse, the system has probably blocked. Say so plainly on the phone: "My jaundice is coming back and I have a biliary stent." That sentence gets the right person on the line.

• MedlinePlus (National Library of Medicine) — Bile duct obstruction
• MedlinePlus (National Library of Medicine) — Percutaneous transhepatic cholangiogram
• StatPearls (NCBI Bookshelf) — Biliary Stenting
• StatPearls (NCBI Bookshelf) — Cholangitis
• CADTH (NCBI Bookshelf) — Nephrostomy and Biliary Tube Management: A Review of the Clinical Evidence and Guidelines
• Cambridge University Hospitals NHS Foundation Trust — Bile duct: going home with an external drain
• Macmillan Cancer Support — Jaundice
• Centers for Disease Control and Prevention — Fever and Cancer Treatment
• National Cancer Institute — Infection and Neutropenia During Cancer Treatment