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A 72-year-old woman presents to the emergency room with classic acute cholecystitis, but she’s too high risk for surgery.  Meanwhile, on the inpatient floor, a patient with hilar cholangiocarcinoma is becoming jaundiced and their bilirubin is climbing.  Two different problems, for both call interventional radiology.

Hi, I’m Dr. Olumide Olulade, an interventional radiologist. And let’s demystify cholecystostomy tubes and biliary drains.  But first we need to review the plumbing. The biliary system begins in the  liver with the intrahepatic ducts,  which drain into the left and right hepatic duct.  These join to form the common hepatic duct  and merge with the cystic duct from the gallbladder to  form the common bile duct, which drains into the duodenum.

So what are the different types of tubes that you might see in the biliary system? A cholecystostomy tube, or chole tube, is a tube that’s placed directly into the gallbladder.  Most often for patients with acute cholecystitis who are too sick to undergo surgery.

A biliary drained by contrast, accesses the bile ducts directly and is typically placed for biliary obstruction, such as from malignancy, strictures, or common bile duct stones that are causing cholangitis or intractable jaundice.  So to sum it up, cholecystostomy tube, or chole tube, equals gallbladder  while biliary drain equals bile duct.

And to take it up a notch, there are two types of biliary drains. An internal-external biliary drain crosses the obstruction,  passes through the sphincter of Oddi and ends up in the duodenum.

This type of drain has side holes, both at the level of the bile ducts, allowing for external drainage, and at the level of the duodenum allowing for internal drainage.

Most interventional radiologists will try to place an internal-external biliary drain, unless the obstruction cannot be crossed.  In these instances,  an external biliary drain that  ends in a bile duct is typically placed.

Most of the time, both cholecystostomy tubes and external biliary drains are connected to a bag for external drainage.  On the other hand, an advantage of internal-external biliary drains, is that a day or so after the procedure, or when the total bilirubin normalizes, the bag can be removed and these drains can be capped for internal drainage.

So let’s apply these to the patients that you got called about.  For the first patient who had acute cholecystitis but was too high risk for surgery, what type of consult would you put in for this patient?

This patient would be appropriate for a cholecystostomy tube. On the other hand, for the patient who had the hilar cholangiocarcinoma and whose tbili was rising and was getting jaundiced, what kind of consult would you put in for this patient?

This patient would be appropriate for a biliary drain. Ideally an internal-external biliary drain.

So what happens with these drains long term? Well, how long the drain stays in depends on the underlying issue. If a cholecystostomy tube was placed for  calculous cholecystitis as in stones in a patient who isn’t a surgical candidate, then the drain may need to stay in long term due to the risk of recurring blockage from the existing stones.

In some cases, we may be able to remove the stones using an IR guided endoscopic procedure, which may allow the drain to come out. On the other hand, if a cholecystostomy tube was placed for  acalculous cholecystitis, then the drain may be able to be removed after the underlying inflammation has resolved. This is usually done after a successful capping trial.

Similarly, a  biliary drain may be discontinued once the underlying issue, such as a common bile duct stone, or malignancy has been treated.  As always, institutional practices and patient context may vary, so it’s always a good idea to check with your local IR team about their specific approach. There’s more than one right way to manage these cases.

And that’s your basic explanation of cholecystostomy tubes and biliary drains. Two drains, two somewhat different jobs, but both can be lifesaving and both are in the IR toolbox. Like, share and stick around for more sharp takes from behind the lead shield. See you on the next one.

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