Clinical presentation and delayed treatment of cholangitis in older people

Acute cholangitis is more common in older people, and increasing age is a determinant of morbidity and mortality, as is early biliary decompression by ERCP. This study aims to identify factors that may contribute to delays in the diagnosis and treatment of older people with acute cholangitis. Case notes of 122 patients (45 aged < 75 years, 77 > 75 years) with a final diagnosis of acute cholangitis who underwent ERCP were reviewed for presenting clinical features (pain, jaundice, rigors, fever, falls, incontinence, confusion), liver function tests, blood count, and the interval from admission to diagnosis, ultrasonography, and ERCP. The most common symptom at presentation was abdominal pain (81%), followed by jaundice (55%). These symptoms were no less common in older patients. Charcot's triad was present in only 15.6% of young and 18.8% of older patients. Jaundice was not detected in 16% of significantly hyperbilirubinemic older patients, but only the presence of functional symptoms was associated with significant diagnostic delay (median, 1 day [range: 0-11] vs. 9.5 days [3-25]; P< 0.001) and delay in performing ERCP (median: 4 days [0-24] vs. 16.5 days [2-29], P< 0.001). Overall mortality was 10%, and the incidence of septic shock was similar in both groups. Charcot's classical triad is infrequent in patients suffering from acute cholangitis. Given the greater difficulty assessing jaundice in older people and the confounding effect of falls, incontinence, and confusion, a routine policy of liver function tests, with further investigation of abnormal results in such presentations, may reduce delays in diagnosing and treating acute cholangitis.