Published online Jan 16, 2019. doi: 10.4253/wjge.v11.i1.41
Peer-review started: July 30, 2018
First decision: October 5, 2018
Revised: October 12, 2018
Accepted: December 12, 2018
Article in press: December 13, 2018
Published online: January 16, 2019
Acute cholangitis is associated with a high mortality when the diagnosis and treatment is delayed. After the diagnosis is made, the most common method for source control is endoscopic retrograde cholangiopancreatography (ERCP). The exact timing of ERCP and its outcomes remains unclear.
The recent 2018 Tokyo guidelines suggest “early” ERCP for mild cholangitis, and “urgent” ERCP for severe cholangitis with no clear defining parameters.
The objectives of this study was to determine the effect of early ERCP vs late ERCP on mortality and readmissions in a large nationally representative sample with acute cholangitis. This could help determine the optimal timing for ERCP as a guide to practicing clinicians.
We used the 2014 National Readmissions Database to identify patients hospitalized with acute cholangitis. Early ERCP was defined as ERCP performed < 48 h from admission, and late ERCP was defined as ERCP performed > 48 h. Multivariate logistic regression was used to calculate the adjusted odds of association of ERCP timing with in-hospital mortality, 30-d mortality, and 30-d readmissions, controlling for age, sex, severe disease and comorbidities.
Four thousand five hundred and ninety-two patients satisfied the inclusion criteria; 65.9% had early ERCP, while 34.1% had late ERCP. Early ERCP was associated with lower in-hospital mortality (1.2% vs 2.4%) adjusted odds ratio (aOR), lower 30-d mortality (1.5% vs 3.3%), and a lower 30-d readmission rate (9.7% vs 15.1%). When stratified by severity of cholangitis, there was a similar benefit.
There is a clear benefit from performing an early ERCP, specifically < 48 h from admission, for biliary drainage in patients with acute cholangitis regardless of severity. The benefits include, lower in-hospital mortality, 30-d mortality, 30-d readmission and reduced hospitalization costs.
Early ERCP seems to offer a mortality benefit compared to later ERCP. This data adds to the body of evidence from other studies about the benefit of early ERCP. Therefore hospitals should have the resources to perform ERCP early in patients with cholangitis, regardless of severity.