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Indications / Contraindications
Indications
- Malignant biliary obstruction (pancreatic cancer, cholangiocarcinoma, HCC, metastatic disease, lymphoma)
- Failed or unsuitable ERCP — post-surgical anatomy, complete obstruction, duodenal obstruction
- Pre-op biliary decompression (controversial; used in select centers)
- Relief of jaundice for chemotherapy eligibility
- Cholangitis from malignant obstruction (urgent)
- Biliary stent dysfunction after prior ERCP stent
Contraindications
- Absolute: Uncorrectable coagulopathy
- Absolute: Massive uncontrolled ascites (relative — transperitoneal approach riskier)
- Relative: Multiple intrahepatic obstructions precluding adequate drainage
- Relative: Diffuse hepatic replacement by tumor (minimal functional liver)
- Relative: Short life expectancy (<1 month) — risk/benefit discussion essential
Malignant Causes by Frequency
- Pancreatic head cancer (~40%): Ampullary region obstruction — classic "double duct sign" on MRCP
- Hilar cholangiocarcinoma (Klatskin tumor): Confluence obstruction → bilateral intrahepatic duct involvement; classified by Bismuth system
- HCC with biliary invasion: Hemobilia and jaundice common
- Colorectal / gastric mets to hepatic hilum: Portal lymphadenopathy pattern
- Lymphoma (periportal nodes): Often responds to chemotherapy — drainage may be temporary
Bismuth Classification (Hilar Tumors)
- Type I: Below CHD confluence — unilateral drainage usually sufficient
- Type II: At confluence — attempt to cross both ducts
- Type IIIa/IIIb: Extends into right or left duct — ipsilateral drainage; contralateral if possible
- Type IV: Bilobar involvement — bilateral drainage rarely provides full benefit; prioritize functional liver volume
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Pre-Procedure Checklist
Review imaging. MRCP or CT to understand anatomy of obstruction — hilar vs. pancreatic head vs. diffuse. Plan which duct system to access. Left approach (segment II/III) preferred for hilar obstruction — better angle to cross, less pneumothorax risk.
Labs (SIR Category 3). CBC, CMP (bilirubin, LFTs), coagulation panel. Target INR <1.5, platelets >50K. Correct with FFP or vitamin K if needed. Bilirubin level establishes baseline for post-procedure tracking.
Antibiotics — non-negotiable. Piperacillin-tazobactam 3.375g IV or ceftriaxone 1g IV + metronidazole 500mg IV at least 1 hour before procedure. Cholangitis is common and the procedure itself can cause bacteremia. Consider extending 24-48h post-procedure.
Sedation plan. Moderate sedation (midazolam + fentanyl) or MAC anesthesia. NPO minimum 6 hours. IV access required. Have anesthesia available for unstable patients or those with cholangitis.
Approach planning. Left approach (subxiphoid, segment II/III ducts) for hilar and pancreatic head obstruction — preferable in most cases. Right approach for isolated right-system disease. Bismuth III-IV may require bilateral drainage.
ERCP coordination. Confirm ERCP was attempted/failed, or that anatomy makes ERCP unfeasible (post-Whipple, duodenal obstruction, complete hilar block). Document in note.
Consent discussion. Sepsis/cholangitis (2-10%), hemorrhage (1-3% major — pseudoaneurysm), bile peritonitis, hemobilia, drain malposition, pleural complication, failed drainage, mortality 0.1-0.8%. Counsel patient on external drain care if internal crossing not achieved.
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Relevant Anatomy
Biliary Tree Overview
- Right hepatic duct (RHHD) from right liver + left hepatic duct (LHD) from left liver → common hepatic duct (CHD) → cystic duct joins → common bile duct (CBD) → ampulla of Vater (drains with pancreatic duct into duodenum)
- Hilar confluence = junction of R + L hepatic ducts. Primary target in Klatskin tumors.
- Segment II/III ducts (left system) are most peripheral, easily visualized from subxiphoid approach, and provide the best angle for crossing hilar/pancreatic head obstructions
Left Hepatic Approach (Preferred)
- Subxiphoid or subcostal skin entry
- Target segment II or III ducts — more peripheral, predictably accessible
- More horizontal angle than right approach — better alignment to cross obstruction into duodenum
- Lower pneumothorax risk — does not traverse intercostal space or pleura
- Preferred for hilar cholangiocarcinoma and pancreatic head obstruction
Right Hepatic Approach
- Right anterior axillary line, 8th–10th intercostal space entry (stay below the 10th rib and anterior to the midaxillary line to minimize the chance of traversing the pleural space). Pleural reflections are at the 8th rib anteriorly, 10th rib laterally, and 12th rib posteriorly.
- AP + oblique fluoroscopic views for targeting
- Pneumothorax risk if above 8th rib — confirm rib level carefully
- Used for isolated right-system obstruction or when left approach fails/not feasible
- Gallbladder and hepatic flexure of colon are nearby — avoid
Danger Structures
- Right approach: Pleura (above 10th rib), gallbladder, hepatic flexure of colon
- Left approach: Stomach (left lobe is anterior to stomach — confirm on US/fluoro), hepatic artery, portal vein branches
- Both approaches: Hepatic artery and portal vein — injuries cause hemobilia and pseudoaneurysm. Recognize hepatic artery access on fluoroscopy by pulsatile contrast flow.
- Fluoroscopic access recognition: Bile duct = slow central contrast column; portal vein = rapid central dilution; hepatic artery = pulsatile flow
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Technique
Default RadCall approach · share your own below
Supplies
Fluoroscopy (C-arm)
21-22G Chiba needle
0.018" wire
AccuStick or Neff coaxial set
0.035" hydrophilic wire (Glidewire)
4-5Fr Kumpe catheter (4Fr fits in an AccuStick set)
8-12 Fr internal-external biliary drainage catheter
10-12 Fr drainage bag
Dilute contrast + syringes
#11 blade
0-silk suture
Internal-External vs. External-Only Drainage
Internal-External — sideholes above AND below obstruction, tip in duodenum
- Drains both to bag AND internally into duodenum
- Bile enters GI tract → physiologically superior
- Requires crossing the obstruction
- Can be capped once patient tolerating oral intake
External Only — all bile drains to external bag
- Used when obstruction cannot be crossed
- All bile to bag — requires bile replacement orally
- Acceptable initial step; reattempt crossing at 48-72h after decompression
Steps
1
Review and plan
Confirm imaging. Identify target duct on MRCP/CT. Mark skin entry site (right = intercostal; left = subcostal/subxiphoid). Ensure antibiotics on board. Confirm ERCP was attempted or is contraindicated.
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Fluoroscopic setup
Position patient supine. AP fluoroscopy to target right liver (intercostal) vs. left liver (subxiphoid). Confirm rib level for right approach to avoid pleura. Apply sterile prep and drape.
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Initial needle access
Advance 21G Chiba needle in breath-hold toward a peripheral duct. Gently withdraw while injecting dilute contrast connected to connector tubing. Look for slow central accumulation = bile duct. Avoid overdistension of the biliary system — this drives bile into blood causing bacteremia.
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Confirm bile duct access
Bile duct: branching ductal pattern, slow contrast column flowing centrally. Portal vein: contrast dilutes rapidly, central flow. Hepatic artery: pulsatile contrast flow. If portal vein or artery: withdraw and redirect.
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Cholangiogram
Carefully delineate biliary anatomy. Identify level and extent of obstruction. Determine Bismuth classification for hilar tumors. Decide if unilateral vs. bilateral drainage is needed. Limit contrast volume to avoid overpressure.
▶ PTBD cholangiogram — biliary anatomy and obstruction level
Diagnostic cholangiogram after initial needle access: map biliary tree, identify level and morphology of obstruction, and plan drain trajectory.
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Wire and dilator
Advance 0.018" wire into system → coaxial system (AccuStick/Neff) → exchange to 0.035" wire → dilate tract to 8 Fr over wire.
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Cross the obstruction
Angled catheter + hydrophilic 0.035" wire technique to cross the stricture into duodenum. Confirm in duodenum with a wire loop and contrast filling the duodenum. If cannot cross = external biliary drainage only — return at 48-72h after decompression.
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Catheter positioning
If obstruction crossed: advance internal-external drainage catheter so sideholes are above AND below the obstruction and tip is in duodenum. If cannot cross: pigtail in the biliary system for external drainage.
▶ Internal-external drain in final position
Internal-external drain placement: catheter tip in duodenum, side holes bracketing the obstruction — confirm pigtail formation and free bile drainage before securing.
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Secure and complete
Flush and aspirate 10 mL to confirm patency. Suture catheter to skin with 0-silk. Connect to external biliary drainage bag. Document bile color and output. Order vitals q30 min x 2h post-procedure.
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Troubleshooting
Problem
Cannot access a dilated duct
Likely cause: Needle not in duct, or ducts not adequately dilated at the puncture site. Peripheral ducts are smaller and easier targets than central ducts.
Next step: Use ultrasound guidance for initial needle targeting — real-time US dramatically improves first-pass success rate. Target more peripheral ducts. Confirm breath-hold technique with patient.
Problem
Cannot cross the obstruction
Likely cause: Tight or complete malignant stricture, wrong angle of approach, or distended upstream system making navigation difficult.
Next step: Consider balloon dilation of the duct and aggressive wire work. External drainage only is an acceptable initial step — decompress the system for 48-72 hours, then return. A decompressed system is significantly easier to navigate. Changing approach (left ↔ right) may improve angle.
Problem
Hemobilia (blood in drainage bag)
Likely cause: Hepatic artery branch injury during access. Small amounts common. Bright red pulsatile output is concerning for pseudoaneurysm.
Next step: Small amounts usually resolve with drainage catheter in place (tamponades the tract). If persistent bright-red pulsatile output → urgent CT angiography → hepatic artery embolization. Never remove the drain prematurely if hemobilia is present.
Problem
Cholangitis / Sepsis post-procedure
Likely cause: Bile contamination into bloodstream from overdistension during cholangiogram or from underlying cholangitis at the time of drainage.
Next step: Blood cultures, broaden antibiotics, ensure drain is patent and draining freely. Vigorous IV fluid resuscitation. ICU if hemodynamically unstable. Confirm drain position and patency with cholangiogram once patient stable.
Problem
Bilateral obstruction — Klatskin tumor
Likely cause: Bismuth III-IV hilar cholangiocarcinoma obstructing both right and left hepatic duct systems independently.
Next step: May need two separate drains (left + right system). Ideally placed same session if patient tolerates; otherwise staged 48 hours apart. Limit to draining the two ducts providing the most functional liver volume. Bismuth IV bilateral drainage rarely achieves meaningful benefit — limit attempts.
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Complications
Immediate / Periprocedural
- Sepsis / cholangitis (2-10%) — leading cause of procedural death; prophylaxis is critical; do not overdistend the biliary system
- Hemorrhage (1-3% major) — hemobilia; hepatic artery pseudoaneurysm → coil embolization
- Bile peritonitis / leak (<1%) — catheter malposition or inadequate seal
- Pleural complication — hemothorax or biliothorax, especially right intercostal approach
- Vasovagal — monitor during and immediately after
Delayed
- Drain occlusion — most common delayed complication; scheduled exchange every 3 months
- Recurrent cholangitis episodes — common with indwelling drain; requires periodic exchange
- Tumor progression — drain dysfunction from tumor ingrowth into metal stent or external compression
- Catheter dislodgement — patient education on drain care is essential
- Mortality — overall 0.1-0.8%; higher in cholangitis and poor performance status
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Post-Procedure Care
Immediate Monitoring
- Vitals q30 min × 2h; biliary drainage output monitoring
- Initial drainage: bile may be thick/sludgy — normal. Dark green-brown = good bile flow
- Watch for fever, rigors, hypotension in first 4h — signs of procedure-induced cholangitis
- Day 2 cholangiogram: confirm catheter position and function
Bile Replacement
- If external drainage only: replace up to 500 mL/day orally (this is not nice to do to patients)
- Bile salts important for fat absorption and production of fat-soluble clotting factors (II, VII, IX, X)
- Patients on external-only drainage are at risk for progressive coagulopathy without bile replacement
- Track daily output volume — expect 200-800 mL/day
Metallic Stent Considerations
- For selected malignant cases: life expectancy >3 months, crossing achieved, patient prefers freedom from exchanges
- Uncovered self-expanding metal stent (SEMS): longer patency (~6-12 months); tumor ingrowth possible; not removable
- Covered SEMS: reduces ingrowth; potentially removable; higher migration risk
- Metal stent placement removes need for scheduled exchange but requires return for re-intervention if dysfunctional
- Oncology coordination: Some chemotherapy regimens require bilirubin normalization — track labs closely after drainage
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Critical Pearls
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Left approach almost always preferred for hilar obstruction — better angle to cross, less pneumothorax risk, segment II/III ducts are reliably accessible from subxiphoid approach.
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Learn the fluoroscopic access signatures: Bile duct = slow contrast column flowing centrally. Portal vein = quick central dilution. Artery = pulsatile flow. This recognition is essential before advancing any wire.
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NEVER overdistend the biliary system — injecting too much contrast raises intrabiliary pressure, driving bile into the bloodstream and triggering bacteremia and sepsis. Use minimal contrast volumes for cholangiography.
✦
Antibiotic prophylaxis is non-negotiable — and consider extending 24-48h post-procedure in patients with established cholangitis or immunosuppression. Piperacillin-tazobactam provides the broadest enteric coverage.
✦
External drainage first, then reattempt crossing at 48-72h — a decompressed biliary system is dramatically easier to navigate than a distended one. Do not struggle to cross a tight stricture in a high-pressure system.
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Bismuth IV tumors: Bilateral drainage rarely achieves meaningful clinical benefit. Limit drainage attempts to 1-2 ducts providing the most functional liver volume. Discuss realistic expectations with the oncology team and patient.
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Metal stents for malignancy: Reserved for patients who have successfully crossed the obstruction, have >3 months life expectancy, and want freedom from scheduled exchanges. Never place a metal stent when there is active cholangitis.
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Biliary Drain Management
| Parameter | Normal / Target | Action / Notes |
|---|---|---|
| Drainage color | Light yellow-green to dark green-brown | Dark = concentrated (normal early); bloody = concerning; frankly bloody pulsatile = urgent CT angio |
| Output volume | 200-800 mL/day expected | Less than 100 mL = possible occlusion (flush, check position); more than 1000 mL = high-output (replace electrolytes) |
| Flushing | 10 mL sterile saline twice daily | Nursing order required; maintains catheter patency; prevents sludge occlusion |
| Capping (internal drainage) | Once adequate oral intake established | Close external drainage valve to promote physiologic bile flow into duodenum; monitor for pain/fever suggesting obstruction |
| Dressing | Every 3-5 days or when soiled | Inspect entry site for erythema, bile leak, or signs of skin breakdown |
| Drain exchange | Every 3 months (sooner if occluded or infected) | Scheduled IR follow-up; cholangiogram at exchange to reassess anatomy |
| Signs of dysfunction | — | Abdominal pain, fever, returning jaundice, change in output volume/color, drain site erythema or leak |
| Lab follow-up | Bilirubin trending down over 1-2 weeks | For chemotherapy eligibility: target bilirubin normalization; coordinate with oncology |
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References & Resources
Primary sources · Key data · Related procedures
Key Guidelines
- SIR Standards of Practice for Biliary Interventions
- ESGAR Guidelines for Biliary Drainage
- CIRSE Standards for Biliary Drainage
Primary References
- Becker CD et al. Percutaneous palliation of malignant obstructive jaundice. AJR Am J Roentgenol. 1989;152(2):249-256.
- Covey AM, Brown KT. Percutaneous transhepatic biliary drainage. Tech Vasc Interv Radiol. 2008;11(1):14-20.
- Murata S et al. Decompression of malignant biliary obstruction. J Vasc Interv Radiol. 2011;22(7):946-953.