Endoscopic Ultrasound (EUS) Guided Biliary Drainage

The bile ducts are tube-like structures that drain bile (a fluid that helps with digestion) from the liver into the small bowel (a part of the gut) so it is passed out of the body. In some cases, such as pancreatic cancer, bile duct cancer, liver cancer or gallstones, the bile ducts can become blocked. This condition is called biliary obstruction. Biliary obstruction may lead to severe problems such as becoming yellow (jaundiced), developing an infection and being very unwell. It is important to find a way to relieve biliary obstruction to improve these problems and symptoms.

The ideal treatment for biliary obstruction is a procedure called endoscopic retrograde cholangiopancreatography (ERCP). This involves unblocking the main bile duct by passing a flexible telescope (called an endoscope) through the mouth and stomach and into the small bowel. In some cases, this procedure is not possible because the blockage causing the biliary obstruction also blocks the small bowel.

Endoscopic ultrasound (EUS) guided biliary drainage involves the insertion of an endoscope with an ultrasound probe at the end to make a new connection between the bile ducts and another part of the gut to allow drainage of bile. A metal tube (called a stent) is placed into the connection to keep it open. The bile duct then drains into the stomach instead of the small bowel. This method can be used when access to the bile duct for an ERCP is not possible.

It has been shown in clinical trials that EUS guided biliary drainage is as effective as the other alternative option, which is to have a drain inserted through the skin and abdominal wall into the bile duct (percutaneous biliary drain).

Percutaneous biliary drainage usually involves a second procedure. Evidence also suggests that EUS guided biliary drainage results in patients spending less time in hospital than patients undergoing percutaneous biliary drainage and requires only one procedure instead of two.

All treatments and procedures have risks and we will talk to you about the risks of EUS guided biliary drainage. There is an overall risk that some sort of complication will occur in 1 in 5 people. This is similar to percutaneous biliary drainage.

Unusual complications which can occur during any procedure that uses EUS include chest infections, damage or a perforation (hole) in the wall of the oesophagus, stomach or small bowel, allergy to sedative medication, bleeding and damage to teeth. 

There are also specific risks which can occur during or after EUS guided biliary drainage.

Problems that may happen straight away

There is a risk of bleeding when the connection between the bile duct and the gut wall is formed. This can occur in 1 in every 20 procedures. You will stay in hospital after the procedure to be observed and if the bleeding is severe you may need an x-ray guided procedure or an operation to stop it.

There is a small chance that the stent may be placed in the wrong place. If this happens you may need a percutaneous drain and an operation performed by a surgeon in the operating theatres to remove the stent.

Problems that may happen later

In approximately 1 in every 20 procedures the stent can become blocked. If this happens you would need to return to hospital for a further procedure to unblock the stent by placing a smaller plastic stent through the first stent.

Occasionally (1 in 40 procedures) the stent may be displaced. This may result in bile leaking into the abdomen which could lead to pain or infection and the need for another drain to be placed.

If you have any pain, fevers or bleeding in the few weeks after the procedure you should contact us immediately (see 'What happens when I go home?').

The main alternative is the placement of a percutaneous drain (a tube through your abdominal wall) as described in section 'How can endoscopic ultrasound guided bile duct drainage help?'.

Other treatment options include a surgical procedure to achieve biliary drainage. However, a less invasive drainage procedure is usually a better option for patients who are very unwell as a result of biliary obstruction, or who have other medical problems that would make an operation high risk.

Since X-rays are sometimes taken during the procedure, please notify the doctor or nurse beforehand if there is any possibility you may be pregnant. 

We will need to know about all the medications you take, in particular blood thinners, such as clopidogrel, warfarin, heparin, rivaroxaban, apixaban or dabigatran. These may need to be stopped or adjusted up to one week before the procedure. 

If you take clopidogrel or other blood thinners it may be necessary to check with your Cardiologist (or other specialist) to be sure that these can be stopped prior to your procedure. 

If you are a diabetic and take insulin, it is important that you continue taking your insulin but we suggest that you reduce your dose the night before and on the day of the procedure. If you are concerned then contact your local diabetes nurse for advice. Remember to check your blood sugar every three to four hours. 

If you are taking tablets for your diabetes, please do not take them on the day of the procedure until after the procedure has been done. Please bring your diabetic tablets or insulin to the hospital with you if you are not already in hospital. 

Please continue to take any other medication (including laxatives). If you are in hospital when the procedure is being done, then doctors on the ward will manage your medicines for you. 

You should not eat anything for six hours before the appointment. 

You may drink water only up until four hours before the procedure (your usual prescription medicines can still be taken after that with a sip of water). 

You will be admitted to the ward overnight following the procedure and so you will need to bring an overnight bag. Please do not bring valuables to the hospital as we cannot accept responsibility for any loss or damage. You may be given injections to thin the blood in order to prevent blood clots while you are in hospital.

We want to involve you in all the decisions about your care and treatment. If you decide to go ahead with treatment, by law we must ask for your consent and will ask you to sign a consent form after one of the doctors has spent time with you face-to-face to go over the procedure in detail. This confirms that you agree to have the procedure and understand what it involves. The doctor will explain all the risks, benefits and alternatives before they ask you to sign a consent form. If you are unsure about any aspect of your proposed treatment at any time, please speak with one of the doctors again.

The procedure is done in the Endoscopy Department and is performed by a specially trained team led by a Gastroenterologist. The procedure is done under sedation or with an anaesthetist putting you to sleep. You will spend up to 60 minutes in the procedure room. 

After the endoscope is passed into the stomach a needle is inserted into the bile duct, using ultrasound guidance. This connection (or tract) is made wider, and then a special type of stent (a partially covered metal stent) is placed through the tract. This creates a new passage which allows the bile duct to drain into the gut. 

This should usually lead to a rapid improvement in symptoms such as jaundice, infection, fatigue and pain. The stent is usually permanent and will not be removed unless you have a complication.

You may wake up with some pain in your abdomen. You will be prescribed pain medication if needed. If your pain is severe or it worsens, then the doctors may check to see if there has been a complication, and so may request a CT (computerised tomography) scan. 

If you are well following your procedure, you will be sent back to the ward. The next morning the team will determine whether you can go home that day. 

If you are taking blood thinning medication we will tell you when you can restart the medication following your procedure. This information will also be provided in your discharge paperwork.

The evidence we have tells us that this is a safe procedure. However, the following symptoms might suggest a complication: 

• Severe persistent pain or worsening jaundice 
• Light-headedness, or fainting 
• Shivering or fever 
• Vomiting of blood 
• Passing of blood or black tar-like stools
• Feeling generally very unwell.

If you have any of these problems please contact the Hepatobiliary Team Pathway Co-ordinator or Specialist Nurse in the first instance.

If you have any of these problems outside office hours, please contact the hospital switchboard and ask to be put through to the on-call Gastroenterology Registrar. In an emergency please visit your nearest Emergency Department. Contact information is provided below.

Endoscopy Booking Team (Monday to Friday 09:00-17:00)
Direct line: 020 3456 7022 
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 67022 
E-mail: uclh.endoscopy@nhs.net 

Endoscopy Recovery (Monday to Friday 09:00-17:00)
Direct line: 020 3447 3282 
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 73282 

Hepatobiliary Pathway Co-ordinator (Monday to Friday 09:30-17:30) 
Direct line: 020 3447 9229 
Switchboard: 0845 155 5000 / 020 3456 7890 ext. 79229 

Hepatobiliary Clinical Nurse Specialist (Monday to Friday 09:00-17:00) 
Mobile: 07967 760 146 

On-call Gastroenterology Registrar (out of hours emergencies only) 
Switchboard: 0845 155 5000 / 020 3456 7890 

Address: Endoscopy Unit, University College Hospital, 2nd Floor Podium, 235 Euston Road, London, NW1 2BU