Why does bile leak around an indwelling biliary drain?
Bile leakage around an indwelling biliary drain can occur for several reasons, and it is a potential complication that needs to be addressed promptly. Some common reasons for bile leakage include:
- Malposition of the Biliary Drain: If the biliary drain is not correctly placed or becomes dislodged, it may not be effectively draining bile from the bile duct. This can lead to bile leakage around the drain site.
- Blockage or Obstruction: Bile ducts can become obstructed due to various reasons, such as the presence of stones, tumors, or strictures. If the biliary drain is unable to bypass the obstruction adequately, bile may leak around the drain.
- Poor Seal or Closure: The connection between the biliary drain and the external drainage system may not form a tight seal, leading to bile leakage.
- Infection or Inflammation: Infections or inflammation around the biliary drain site can compromise the integrity of the tissues and allow bile to leak.
- Bile Duct Perforation: In some cases, the bile duct itself may be perforated during the insertion of the biliary drain, leading to bile leakage.
- Catheter or Drainage Tube Complications: Issues with the catheter or drainage tube, such as kinking, bending, or blockage, can result in inadequate drainage and bile leakage.
- Increased Bile Pressure: Certain conditions, such as choledocholithiasis (gallstones in the common bile duct) or biliary strictures, can cause an increase in bile pressure, leading to bile leakage.
Bile leakage around an indwelling biliary drain can be associated with significant risks, including infection, peritonitis (inflammation of the abdominal lining), and sepsis (bloodstream infection). Therefore, it is crucial to promptly address any signs of bile leakage or other complications associated with the biliary drain.
Biliary drains require considerable maintenance after they are placed, and the maintenance often adversely affects the quality of life of patients.
Leakage occurs for various reasons. Standard biliary tubes consist of a catheter with side holes and a distal locking loop. For the tube to work properly, the side holes must be patent and properly positioned.
The key to proper positioning is the proper location of the most peripheral side hole. This hole should be located just inside the biliary duct where access was obtained. If the most peripheral side hole of the catheter is malpositioned, leakage can occur.
Migration or malposition of the tube so that the hole is outside of the duct and in the parenchymal tract results in bile leaking back along the catheter onto the skin.
If the hole is too far in, the bile duct peripheral to the catheter may become obstructed and leak along the course of the catheter.
Meticulous tube placement, a cholangiogram that confirms proper positioning, along with good technique in securing the catheter to the skin surface will help to prevent these problems.
Another common cause of leakage is clogging of the side holes of the catheter with viscous bile or duct debris.
This situation can be managed via catheter exchange with consideration given to upsizing the tube if the complication occurs frequently.
As a general rule, long-term biliary drainage catheters are exchanged every 3 months for preventive maintenance.
Biliary drains have further holes along the shaft of the drain for a variable length. When planning drainage procedures it is important to assess the need for extra side holes along the shaft. If required these can be tailor-made using a scalpel. Extreme caution is required not to weaken the drain or damage the locking thread within the tube.
Extra holes can be cut in larger drains by kinking the drain and cutting across the corner.
If bile leakage is suspected or observed, the healthcare team will typically assess the patient’s condition, investigate the cause of the leakage, and take appropriate measures to manage the situation. This may involve repositioning or replacing the biliary drain, managing any underlying obstructions, ensuring proper drainage, and providing appropriate antibiotics or other interventions to address infection and inflammation. Close monitoring and follow-up are essential to ensure the proper functioning of the biliary drainage system and prevent further complications.