Optimal Timing of Endoscopic Retrograde Cholangiopancreatography in Acute Cholangitis

Acute cholangitis mandates resuscitation, antibiotic therapy, and biliary decompression. Our aim was to define the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis.

Clinical data on all cases of cholangitis managed by ERCP were prospectively collected from September 2010 to July 2013. The clinical impact of the time to ERCP, defined as the time from presentation in the emergency department to the commencement of the ERCP, was determined. The primary outcome was length of hospitalization. Secondary outcomes included vasopressor use, endotracheal intubation, intensive care unit admission, and death.

ERCP was successful in 182 (92%) of 199 patients with cholangitis. Length of hospitalization was significantly longer for patients undergoing ERCP at ≥48 versus <48 hours (median 9.1 vs. 6.5 d, P=0.004) even though patients having ERCP at ≥48 hours were less sick as indicated by less frequent intensive care unit admission [odds ratio,0.3; 95% confidence interval (CI), 0.2-0.6]. Multivariate analysis revealed that hospitalization increased by 1.44 days for every day ERCP was delayed (P<0.001). Comparison of ERCP≥72 versus <72 hours revealed odds ratios of 2.6 (95% CI, 1.0-7.0) for vasopressor requirement and 3.6 (95% CI, 0.8-15.9) for mortality. Time to ERCP did not impact technical success or procedural adverse events.

ERCP should be performed within 2 days of presentation as a delay of 48 or more hours is associated with disproportionate increase in hospital stay. Delay>72 hours is associated with additional adverse outcomes including hypotension requiring vasopressor support.