Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis

Patient Safety and Care After Outpatient Endoscopic Retrograde Cholangiopancreatography (ERCP): A Single-Center Experience in Germany

The current goal of adapting care structures in the German healthcare system is to increase the provision of interventional treatments in outpatient settings. Endoscopic Retrograde Cholangiopancreatography (ERCP) procedures were traditionally performed in an inpatient setting until 2022. However, with the introduction of a new Ambulatory Surgery Contract (according to Section 115b, Paragraph 1 of the Social Code, Book V) on January 1, 2023, these procedures are now intended to be carried out more strictly on an outpatient basis, meaning that hospitalization will no longer be reimbursed in most cases.Between June 1, 2023, and December 31, 2023 all ERCP procedures performed in an outpatient setting were included in this study. This cohort had standard ERCP indications and a low comorbidity burden according to the §115b specifications. Using propensity score matching (nearest-neighbor), these cases were matched with patients who underwent ERCP procedures in an inpatient setting between June 1, 2022, and December 31, 2022.Propensity-score matching identified a cohort of 166 patients (83 outpatients and 83 inpatients) with similar baseline characteristics. The most common indications for ERCP were choledocholithiasis and biliary strictures. Reported complications comprised pancreatitis, bleeding and cholangitis and were rare in both groups, occurring in 7% of inpatient procedures and in 6% of outpatient procedures. The latter cases required inpatient admission after self-presenting to the emergency department. No serious adverse events were reported.Outpatient ERCP is a safe procedure for selected patients with a low risk profile. Complications occurred rarely and could be adequately managed.

Urgent Endoscopic Biliary Procedures: "Run Like the Wind"?

Emergency endoscopy is an activity that must be guaranteed 7 days a week and 24 h a day. The pathologies of endoscopic interest that require emergency intervention are mainly hemorrhages of the upper digestive tract, the removal of foreign bodies, and the ingestion of caustics. The emergency endoscopist must therefore be experienced in the management of these pathologies. Nowadays, however, we know that even some biliary tract pathologies must be managed within a variable period between 12 and 72 h, in particular acute cholangitis (Ach), acute biliary pancreatitis (ABP), biliary duct leaks (BDLs), and acute cholecystitis (AC). If, on one hand, there is little awareness among doctors about which pathologies of the biliary tract really deserve urgent treatment, on the other, the international guidelines, although not uniformly, have acquired the results of the studies and have clarified that only severe Ach should be treated within 12 h; in other cases, endoscopic treatment can be delayed up to 72 h according to the specific condition. This obviously has a significant organizational implication, as not all endoscopists have training in biliary tract endoscopy, and guaranteeing the availability of a biliary endoscopist 24/7 may be incompatible with respecting the working hours of individual professionals. This review aims to evaluate which pathologies of the biliary tract really require an endoscopic approach in emergency or urgency and the organizational consequences that this can determine. Based on the guidelines, we can conclude that a daytime availability for urgent biliary tract procedures 7 days a week should be provided for the management of severe ACh. Patients with ABP, AC unfit for surgery, and not responsive to medical therapy or BDLs can be treated over a longer period, allowing its scheduling on the first available day of the week.

On-site ERCP availability and cholangitis outcomes: Retrospective cohort study

Background and study aims

Endoscopic retrograde cholangiopancreatography (ERCP) is important in acute cholangitis (AC) management but is not available at all hospitals. The association between on-site ERCP availability and cholangitis outcomes is unknown.

Patients and methods

We included adults diagnosed with AC at 27 hospitals in Ontario through the GEMINI network. We collected data on demographics, clinical and laboratory values, and interventions. The primary outcome was in-hospital mortality. Secondary outcomes were length of stay, intensive care unit (ICU) admission, readmission rates, and requirement for percutaneous or surgical decompression. We used multivariable regression analyses to assess the impact of on-site ERCP availability on the primary and secondary outcomes with adjustment for relevant variables.

Results

Our cohort included 4492 patients with a median age of 75. Patients at ERCP sites had higher unadjusted rates of undergoing ERCP (55.7% at ERCP sites, 40.8% at non-ERCP sites). Patients at ERCP sites compared with non-ERCP sites did not have significantly different in-hospital mortality (adjusted odds ratio [aOR] = 2.19, 95% confidence interval [CI] = 0.86-5.55). Compared with non-ERCP sites, patients at ERCP sites with underlying stricturing biliary disease or pancreaticobiliary malignancy (aOR = 1.94, 95% CI = 1.14-13.58) or severe cholangitis (aOR = 2.17, 95% CI = 1.17-4.02) had higher odds of in-hospital mortality. In a post-hoc propensity score-based analysis, there was no significant difference between patients at ERCP sites compared with those at non-ERCP sites for in-hospital mortality.

Conclusions

Patients at ERCP sites compared with non-ERCP sites did not have significantly different mortality. Subgroups of patients with underlying stricturing biliary disease or pancreaticobiliary malignancy and severe cholangitis, who have higher mortality at ERCP sites, warrant further study.

Impact of timing of ERCP on long term outcomes of ERCP for acute cholangitis - A single center retrospective study

INTRODUCTION

Acute cholangitis is a critical medical emergency. The association between the timing of ERCP and clinical outcomes of acute cholangitis is still debated. The current study aims to evaluate whether ERCP within 48 h (urgent) is associated with improved long term clinical outcomes.

METHODS

This study is a single-center retrospective analysis of a prospectively maintained database. All patients admitted with acute cholangitis as per Tokyo guidelines at AIG Hospitals, Hyderabad between January 2022 to December 2022 were included. We evaluated the association between urgent ERCP and length of hospital stay, need for reintervention and readmissions, and mortality.

RESULTS

A total of consecutive 301 patients underwent ERCP for acute cholangitis; of which 217 patients (31.3 % females; mean age 54.02 ± 14.9 years) underwent urgent ERCP. The remaining 84 (32.1 % females; mean age 56.56 ± 13.9 years) underwent routine ERCP. Fifty-eight (26.7 %) and 22 (26.2 %) patients with Grade III underwent urgent and routine ERCP respectively. The median (IQR) hospital stay for urgent ERCP was 8.00 (6.00 - 11.00) days and for routine ERCP was 11.00(8.00 - 15.00; p value 0.0001), with similar hospital stay post ERCP (p 0.26). There was no significant difference in mortality upto one year between patients who underwent urgent (22.1 %;48/217) or routine ERCP (31.0 %;26/84, p 0.135). The cox proportional hazard model showed that mortality is independently associated with older age (HR 1.034;95 %CI: 1.013 - 1.054; p 0.001) and malignancy (HR 8.64;95 %CI:4.728 - 15.790; p 0.0001). There was no significant difference between two groups in terms of need for reinterventions and readmissions.

CONCLUSIONS

Urgent ERCP for acute cholangitis is associated comparable overall mortality, need for reinterventions, and readmissions with decreased total length of hospital stay. There is an unmet need to confirm these findings by randomized controlled studies.

Red cell distribution width-to-albumin ratio is a simple promising prognostic marker in acute cholangitis requiring biliary drainage

BACKGROUND

It is crucial to assess the severity of acute cholangitis (AC). There are currently several prognostic markers. However, the accuracies of these markers are not satisfied. The present study aimed to investigate the predictive value of the red cell distribution width (RDW)-to-albumin ratio (RAR) for the prognosis of AC.

METHODS

We retrospectively evaluated consecutive patients diagnosed with AC between May 2019 and March 2022. RAR was calculated, and its predictive ability for in-hospital mortality, intensive care unit (ICU) admission, bacteremia, and the length of hospitalization were analyzed.

RESULTS

Out of 438 patients, 34 (7.8%) died. Multivariate analysis showed that malignant etiology [odds ratio (OR) = 4.816, 95% confidence interval (CI): 1.936-11.980], creatinine (OR = 1.649, 95% CI: 1.095-2.484), and RAR (OR = 2.064, 95% CI: 1.494-2.851) were independent risk factors for mortality. When adjusted for relevant covariates, including age, sex, malignant etiology, Tokyo severity grading (TSG), Charlson comorbidity index, and creatinine, RAR significantly predicted mortality (adjusted OR = 1.833, 95% CI: 1.280-2.624). When the cut-off of RAR was set to 3.8, its sensitivity and specificity for mortality were 94.1% and 56.7%, respectively. Patients with an RAR of > 3.8 had a 20.9-fold (OR = 20.9, 95% CI: 4.9-88.6) greater risk of mortality than the remaining patients. The area under the curve value of RAR for mortality was 0.835 (95% CI: 0.770-0.901), which was significantly higher than that of TSG and the other prognostic markers, such as C-reactive protein-to-albumin ratio, and procalcitonin-to-albumin ratio. Lastly, RAR was not inferior to TSG in predicting ICU admission, bacteremia, and the length of hospitalization.

CONCLUSIONS

RAR successfully predicted the in-hospital mortality, ICU admission, bacteremia, and the length of hospitalization of patients with AC, especially in-hospital mortality. RAR is a promising marker that is more convenient than TSG and other prognostic markers for predicting the prognosis of patients with AC.

Urgent Endoscopic Retrograde Cholangiopancreatography Treatment Useful for Acute Cholangitis Caused by Bile Duct Stones in Patients Aged 90 Years and Older

BACKGROUND

Recently, the incidence of acute obstructive cholangitis caused by bile duct stones in patients aged 90 years and older (super-old) has been increasing, for which urgent endoscopic retrograde cholangiopancreatography (ERCP) treatment may be required. The aim of this study was to evaluate the efficacy and safety of urgent ERCP in super-old patients with acute cholangitis caused by bile duct stones.

METHODS

A total 147 consecutive patients aged between 75 and 99 years who underwent urgent ERCP for acute cholangitis caused by bile duct stones were analyzed in a retrospective manner. They were divided into the old (age 75-89 years, control) and super-old (age 90-99 years) groups. Urgent ERCP efficacy and safety, including general status, ERCP-related findings and outcomes, cardiopulmonary monitoring during ERCP, and mortality, were compared between the groups.

RESULTS

The physical status of the super-old group was worse than that of the old group. The success rates for biliary drainage and complete clearance of bile duct stones at the first attempt in the super-old group were lower as compared to the old group, while those after two attempts increased in the super-old group and were nearly the same as in the old group. No fatal cardiopulmonary complications during ERCP were observed in either group. Mortality rate within 2 months was higher in the super-old group, though recovered to the same level as in the old group after 2 months.

CONCLUSIONS

Efficacy and safety of urgent ERCP treatment in super-old patients were comparable to those seen in old patients, though the overall trend indicated greater difficulty. Urgent ERCP treatment can be useful for acute cholangitis caused by bile duct stones in super-old patients.

Part 2: Current Concepts in Radiologic Imaging & Intervention in Acute Biliary Tract Diseases

Acute cholangitis is encountered commonly in critically ill, often elderly, patients. The most common causes of cholangitis include choledocholithiasis, biliary strictures, and infection from previous endoscopic, percutaneous, or surgical intervention of the biliary tract. Rare causes of acute cholangitis in the United States include sclerosing cholangitis and recurrent pyogenic cholangitis, the latter predominantly occurring in immigrants of Asian descent. Multidisciplinary management of these conditions is essential, with intensivists, surgeons, diagnostic radiologists, interventional radiologists, gastroenterologists, endoscopists, and infectious disease physicians typically involved in the care of these patients. In this paper intended for intensivists predominantly, we will review the imaging findings and radiologic interventional management of critically ill patients with acute cholangitis, primary and secondary sclerosing cholangitis, and recurrent pyogenic cholangitis.

Urgent one-stage endoscopic treatment for choledocholithiasis related moderate to severe acute cholangitis: A propensity score-matched analysis

BACKGROUND

During emergency endoscopic retrograde cholangiopancreatography (ERCP), the safety and feasibility of performing one-stage endoscopic treatment for patients with acute cholangitis (AC) due to choledocholithiasis are unclear.

AIM

To investigate the safety and feasibility of one-stage endoscopic treatment for moderate to severe AC.

METHODS

We enrolled all patients diagnosed with moderate to severe cholangitis due to common bile duct stones from January 2019 to July 2023. The outcomes were compared in this study between patients who underwent ERCP within 24 h and those who underwent ERCP 24 h later, employing a propensity score (PS) framework. Our primary outcomes were intensive care unit (ICU) admission rates, ICU length of stay, and duration of antibiotic use.

RESULTS

In total, we included 254 patients and categorized them into two groups based on the time elapsed between admission and intervention: The urgent group (≤ 24 h, n = 102) and the elective group (> 24 h, n = 152). Ninety-three pairs of patients with similar characteristics were selected by PS matching. The urgent ERCP group had more ICU admissions (34.4% vs 21.5%, P = 0.05), shorter ICU stays (3 d vs 9 d, P < 0.001), fewer antibiotic use (6 d vs 9 d, P < 0.001), and shorter hospital stays (9 d vs 18.5 d, P < 0.001). There were no significant differences observed in adverse events, in-hospital mortality, recurrent cholangitis occurrence, 30-d readmission rate or 30-d mortality.

CONCLUSION

Urgent one-stage ERCP provides the advantages of a shorter ICU stay, a shorter duration of antibiotic use, and a shorter hospital stay.

Incidence and outcomes in patients with acute cholangitis: a population-based study

OBJECTIVE

The importance of early ERCP (endoscopic retrograde cholangiopancreatography) in patients with acute cholangitis (AC) is controversial. The aims were to compare outcomes in those who had early ERCP within 24 h from diagnosis and those who had ERCP undertaken later and examine the general prognosis of AC patients.

METHODS

A prospective endoscopic database was used to identify all patients who underwent ERCP 2010-2021 at Landspitali University Hospital, diagnosed with cholangitis (k83.0) or calculus of bile duct with cholangitis (k80.3) according to ICD-10 diagnostic codes. Tokyo guidelines were used to verify the diagnosis and severity. Sepsis was analyzed by the Sepsis-3 criteria.

RESULTS

A total of 240 patients met the inclusion criteria, 107 women (45%), median age 74 years, mostly due to gallstones (75%) and malignancy (19%), 61 (25%) underwent ERCP early. Overall 30-day mortality was 3.3% and was not significantly different between the early and late ERCP groups (4.9% vs 2.5% respectively). Patients who underwent early ERCP were more likely to have severe cholangitis according to the Tokyo guidelines criteria than those who underwent ERCP later (31% vs 18%, p = 0.047) but had a shorter median hospital stay (4 vs. 6 days, p = 0.006). Sepsis was more common among those who had ERCP early than those who had late ERCP (33% vs 19%, p = 0.033).

CONCLUSIONS

The results indicate that for patients with AC the timing of ERCP is an important factor influencing the hospital stay, with shorter hospital stay for patients receiveing ERCP within 24 h, despite more severe cholangitis at diagnosis.

Outcomes and predictors of delayed endoscopic biliary drainage for severe acute cholangitis due to choledocholithiasis in an intensive care unit

BACKGROUND

Acute cholangitis (AC) is an infection of the biliary tract secondary to biliary obstruction requiring biliary drainage through endoscopic retrograde cholangiopancreatography. This study aims to compare the outcome between the early and delayed ERCP in patients with severe AC.

METHODS

Patient with severe AC due to choledocholithiasis admitted to intensive care unit were included. Early ERCP was defined was as ERCP performed within 24 h following hospital admission. Propensity-score matching was used to reduce the imbalance between groups. The primary outcome was 30-day mortality. Secondary outcomes included length of hospital and ICU stay, onset or persistent organ failure.

RESULTS

The delayed ERCP group had a higher mortality rate at 30 days (45,5 versus 13%, <0.001) and at 1 year (59,7% versus 15,6%, p <0.001). Delayed ERCP had also a higher rate of respiratory adverse events (54,5 versus 27,8%, p = 0,002), longer ICU (7.41 versus 4.61, p = 0,004) and hospital (11,88 versus 9,22, p = 0,042) length of stay. Predictors of delayed ERCP were cardiac arrythmias, liver disease, creatinine value and white blood cell count at baseline.

CONCLUSIONS

Delays in ERCP for patients with severe AC appear to be associated with higher mortality rate and prolonged ICU and hospital stays.

Early is Not Superior to Late Endoscopic Intervention for Acute Cholangitis

BACKGROUND

Acute cholangitis (AC) is a common emergency with a significant mortality risk. This study aimed to compare urgent, early, and late endoscopic retrograde cholangiopancreatography (ERCP) for AC.

METHOD

We retrospectively evaluated patients diagnosed with AC from June 2016 to May 2021. According to the time of ERCP, patients were divided into urgent (≤24 h), early (24-48 h), and late (≥48 h) groups. Primary outcomes were technical success, in-hospital mortality, and 30-day mortality. Secondary outcomes were the length of hospital stay (LOS), ERCP-related adverse events, and 30-day readmission.

RESULTS

We divided 121 patients who underwent ERCP into urgent (N = 15), early (N = 19), and late groups (N = 87). There was no in-hospital mortality and no significant difference in technical success (93.3% (urgent) vs 89.5% (early) vs 96.6% (late); P = .41) and 30-day mortality (P = .82). LOS in the urgent and early groups was shorter than that in the late group (13.93 days vs 8.82 days vs 14.20 days, respectively; P = .02). There was no difference between groups for ERCP-related adverse events and 30-day readmission rates.

CONCLUSIONS

Urgent or early ERCP was not superior to late ERCP for technical success and 30-day mortality. However, urgent or early ERCP was associated with shorter LOS than late ERCP.

Early Biliary Decompression Reduces Morbidity but Not Mortality in Acute Ascending Cholangitis

Background Acute ascending cholangitis is a life-threatening infection due to biliary obstruction. Decompression via endoscopic retrograde cholangiography (ERC) or interventional radiologic (IR) drainage controls the source of the sepsis. Numerous studies have been published with conflicting data on whether earlier drainage affects morbidity and mortality. We sought to publish our experience at two Las Vegas community hospitals. Methods After IRB approval, over 4000 inpatient non-elective ERCs were analyzed between 2010 and 2019. Six-hundred and twenty-five patients met the 2018 Tokyo criteria for a "definitive diagnosis" of acute ascending cholangitis. A univariate and multivariate analysis was conducted to identify factors significantly associated with length of stay and mortality. Results On univariate analysis, patients who had drainage conducted within 24 hours had significantly shorter lengths of stay (p = 0.0012 95% CI [-88.1 to -21.8 hrs]), higher mean diastolic blood pressure (p=0.0029 95% CI [1.03 to 5.01 mm Hg]), and lower mean maximum temperature (p=0.0001 95% CI [-0.842 to -0.382 ^oC]) when compared to patients who underwent decompression more than 24 hours after admission. There were no statistically significant differences in mortality between patients who underwent decompression within 24 hours of admission versus patients who underwent decompression beyond 24 hours of admission. On multivariate analysis, earlier decompression reduced the length of stay for patients with mild (p<0.0001), moderate (p<0.0001), and severe cholangitis (p=0.0023). Mortality was significantly associated with the worsening severity of the cholangitis (moderate [p=0.0001] and severe [p<0.0001], but not mild disease) and the use of vasopressors. Conclusions Timely biliary decompression within 24 hours of admission significantly reduces the length of stay, pyrexia, and hemodynamic abnormalities. In addition, our data corroborate the 2018 Tokyo guidelines that correlate the severity of cholangitis with mortality.

Can endoscopic retrograde cholangiopancreatography-related procedures for resolving acute cholangitis be effectively and safely performed in patients with surgically altered anatomy? Comparison study to evaluate the timing of short-type single-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreatography

OBJECTIVES

Balloon enteroscopy (BE)-assisted endoscopic retrograde cholangiopancreatography (ERCP)-related procedures to resolve acute cholangitis (AC) in patients with surgically altered anatomy (SAA) are limited. There is a lack of evidence on whether the timing of BE-assisted ERCP affects clinical outcomes in patients with AC. This study aimed to evaluate the clinical outcomes of short-type single-balloon enteroscopy (short SBE)-assisted ERCP in patients with SAA and AC.

METHODS

Patients with AC who underwent short SBE-assisted ERCP procedures between September 2011 and April 2022 were retrospectively reviewed. The outcomes of procedures undergone at ≤24 h and >24 h were compared. The primary outcome was the length of stay (LOS).

RESULTS

Overall, 56 patients underwent procedures at ≤24 h, and 58 patients at >24 h. The procedural success and adverse event rates of short SBE-assisted ERCP were 87.7% (95% confidence interval [CI] 80.3-93.1%) and 4.4% (95% CI 1.4-9.9%), respectively. Patients with severe (Grade III) AC and systemic inflammatory response syndrome were more in early (at ≤24 h) ERCP groups. LOS and median time from ERCP procedures to discharge were shorter in the early group. Procedural success and adverse event rates between both groups had no significant differences. Multivariable linear regression analysis showed that ERCP performed at ≤24 h was associated with shorter LOS, while severe cholangitis and malignant biliary obstruction were associated with longer LOS.

CONCLUSIONS

Short SBE-assisted ERCP is effective and safe in patients with SAA and AC. Early procedures seemed to attribute early improvement of general condition, thus shortening the LOS.

Urgent and emergency endoscopic retrograde cholangiopancreatography for gallstone-induced acute cholangitis and pancreatitis

Urgent or emergency endoscopic retrograde cholangiopancreatography (ERCP) is indicated for gallstone-induced acute cholangitis and pancreatitis. The technique and optimal timing of ERCP depend on the disease state, its severity, anatomy, patient background, and the institutional situation. Endoscopic transpapillary biliary drainage within 24 h is recommended for moderate to severe acute cholangitis. The clinical outcomes of biliary drainage with nasobiliary drainage tube placement and plastic stent placement are comparable, and the choice is made on a case-by-case basis considering the advantages and disadvantages of each. The addition of endoscopic sphincterotomy (EST) is basically not necessary when performing drainage alone, but single-session stone removal following EST is acceptable in mild to moderate cholangitis cases without antithrombotic therapy or coagulopathy. For gallstone pancreatitis, early ERCP/EST are recommended in cases with impacted gallstones in the papilla. In some cases of gallstone pancreatitis, a gallstone impacted in the papilla has already spontaneously passed into the duodenum, and early ERCP/EST lacks efficacy in such cases, with unfavorable findings of cholangitis or cholestasis. If it is difficult to diagnose the presence of gallstones impacted in the papilla on imaging, endoscopic ultrasonography can be useful in determining the indication for ERCP.

Racial disparities in endoscopic retrograde cholangiopancreatography (ERCP) utilization in the United States: are we getting better?

BACKGROUND

We identified trends of inpatient therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in the United States (US), focusing on outcomes related to specific patient demographics.

METHODS

The National Inpatient Sample was utilized to identify all adult inpatient ERCP in the US between 2007-2018. Trends of utilization and adverse outcomes were highlighted. P-values ≤ 0.05 were considered statistically significant.

RESULTS

We noted a rising trend for total inpatient ERCP in the US from 126,921 in 2007 to 165,555 in 2018 (p = 0.0004), with a significant increase in utilization for Blacks, Hispanics, and Asians. Despite an increasing comorbidity burden [Charlson Comorbidity Index (CCI) score ≥ 2], the overall inpatient mortality declined from 1.56% [2007] to 1.46% [2018] without a statistically significant trend (p = 0.14). Moreover, there was a rising trend of inpatient mortality for Black and Hispanic populations, while a decline was noted for Asians. After a comparative analysis, we noted higher rates of inpatient mortality for Blacks (2.4% vs 1.82%, p = 0.0112) and Hispanics (1.17% vs 0.83%, p = 0.0052) at urban teaching hospitals between July toand September compared to the October to June study period; however, we did not find a statistically significant difference for the Asian cohort (1.9% vs 2.10%, p = 0.56). The mean length of stay (LOS) decreased from 7 days in 2007 to 6 days in 2018 (p < 0.0001), while the mean total hospital charge (THC) increased from $48,883 in 2007 to $85,909 in 2018 (p < 0.0001) for inpatient ERCPs. Compared to the 2015-2018 study period, we noted higher rates of post-ERCP pancreatitis (27.76% vs 17.25%, p < 0.0001) from 2007-2014.

CONCLUSION

Therapeutic ERCP utilization and inpatient mortality were on the rise for a subset of the American minority population, including Black and Hispanics.

Timing of endoscopic retrograde cholangiopancreatography in the treatment of acute cholangitis of different severity

BACKGROUND

The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis (AC) is uncertain, especially in patients with AC of varying severity.

AIM

To report whether the timing of ERCP is associated with outcomes in AC patients with different severities.

METHODS

According to the 2018 Tokyo guidelines, 683 patients who met the definite diagnostic criteria for AC were retrospectively identified. The results were first compared between patients receiving ERCP ≤ 24 h and > 24 h and then between patients receiving ERCP ≤ 48 h and > 48 h. Subgroup analyses were performed in patients with grade I, II or III AC. The primary outcome was 30-d mortality. Secondary outcomes were intensive care unit (ICU) admission rate, length of hospital stay (LOHS) and 30-d readmission rate.

RESULTS

Taking 24 h as the critical value, compared with ERCP > 24 h, malignant biliary obstruction as a cause of AC was significantly less common in the ERCP ≤ 24 h group (5.2% vs 11.5%). The proportion of cardiovascular dysfunction (11.2% vs 2.6%), respiratory dysfunction (14.2% vs 5.3%), and ICU admission (11.2% vs 4%) in the ERCP ≤ 24 h group was significantly higher, while the LOHS was significantly shorter (median, 6 d vs 7 d). Stratified by the severity of AC, higher ICU admission was only observed in grade III AC and shorter LOHS was only observed in grade I and II AC. There were no significant differences in 30-d mortality between groups, either in the overall population or in patients with grade I, II or III AC. With 48 h as the critical value, compared with ERCP > 48 h, the proportion of choledocholithiasis as the cause of AC was significantly higher in the ERCP ≤ 48 h group (81.5% vs 68.3%). The ERCP ≤ 48 h group had significantly lower 30-d mortality (0 vs 1.9%) and shorter LOHS (6 d vs 8 d). Stratified by AC severity, lower 30-d mortality (0 vs 6.1%) and higher ICU admission rates (22.2% vs 10.2%) were only observed in grade III AC, and shorter LOHS was only observed in grade I and II AC. In the multivariate analysis, cardiovascular dysfunction and time to ERCP were two independent factors associated with 30-d mortality.

CONCLUSION

ERCP ≤ 48 h conferred a survival benefit in patients with grade III AC. Early ERCP shortened the LOHS in patients with grade I and II AC.

Impact of the Timing of Endoscopic Retrograde Cholangiopancreatography for the Treatment of Acute Cholangitis: A Meta-analysis and Systematic Review

BACKGROUND

The optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) for acute cholangitis (AC) has not been unequivocally established.

AIMS

To perform a meta-analysis of the outcomes associated with particular timings of ERCP for AC.

METHODS

A systematic literature search was conducted for studies of ERCP for AC, and then a meta-analysis of the in-hospital mortality (IHM), 30-day mortality, and length of hospital stay (LHS) was performed.

RESULTS

Seven non-randomized studies of 88,562 patients were considered appropriate for inclusion. Compared with performing ERCP more than 24 hours after admission, ERCP within 24 hours was associated with lower IHM ( P <0.0004), but no difference in 30-day mortality ( P =0.38) was found between the 2 groups. ERCP performed <48 hours after admission was associated with a lower IHM and 30-day mortality ( P <0.00001 and P =0.03) than ERCP performed >48 hours after admission. In addition, ERCP performed within 24 or 48 hours was associated with a shorter LHS ( P <0.00001 and P <0.00001, respectively).

CONCLUSION

ERCP within 48 hours of admission is superior to subsequent ERCP with respect to IHM, 30-day mortality, and LHS, and ERCP performed within 24 hours is associated with lower IHM and LHS.

Optimal timing of biliary drainage based on the severity of acute cholangitis: A single-center retrospective cohort study

BACKGROUND

Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.

AIM

To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.

METHODS

In this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)].

RESULTS

Biliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).

CONCLUSION

Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.

Emergency Endoscopic Retrograde Cholangiopancreatography Did Not Increase the Incidence of Postprocedural Pancreatitis Compared With Elective Cases: A Prospective Multicenter Observational Study

OBJECTIVE

The aim of this study was to identify the incidence of and risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) after emergency endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

We performed a prospective multicenter observational study of 3914 patients who underwent ERCP. We compared the incidence of PEP after emergency and elective ERCP.

RESULTS

A total of 3410 patients were enrolled in this study. Post-ERCP pancreatitis occurred in 44 of 800 patients (5.5%) and in 190 of 2418 patients (7.9%) in the emergency and elective groups, respectively. No significant difference was noted between the groups (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.52-1.03; P = 0.07). Multivariate analysis showed that the following factors increased the risk for PEP after emergency ERCP: contrast medium injection into the pancreatic duct (OR, 2.56; 95% CI, 1.30-5.03; P = 0.005), >4 cannulation attempts (OR, 5.72; 95% CI, 2.61-12.50; P < 0.001), and endoscopic papillary balloon dilatation (OR, 9.24; 95% CI, 2.13-40.10; P < 0.001).

CONCLUSIONS

No significant difference was noted in the incidence of PEP in patients after emergency and elective ERCP. We may prevent PEP even after emergency ERCP by avoiding contrast injection into the pancreatic duct, multiple cannulation attempts, and endoscopic papillary balloon dilatation.

Effect of Antibiotic Resistance of Pathogens on Initial Antibiotic Therapy for Patients With Cholangitis

Objectives

Considering that pathogens resistant to initial antibiotic therapies for cholangitis can affect mortality rates, appropriate initial empiric antibiotic therapy is important. However, evidence regarding the influence of pathogens resistant to initial antibiotics in patients with cholangitis who have undergone early endoscopic retrograde cholangiopancreatography (ERCP) is limited, and the conditions in several cases can improve with early ERCP even when pathogens resistant to initial antibiotics are detected on time. Therefore, this study aimed to assess the influence of pathogens resistant to initial antibiotics on the course of cholangitis in patients undergoing early ERCP.

Materials and methods

Patients (n=266) with positive blood or bile culture results treated with early ERCP were divided into those with cultures that were resistant to the initial antibiotics (antibiotic-resistant group; n=66; 24.8%) and those with cultures that were sensitive to the initial antibiotics (antibiotic-sensitive group; n=200; 75.2%). The duration of hospitalization, in-hospital mortality rates due to cholangitis, rates of increased disease severity, and complications during hospitalization were studied.

Results

Enterococcus, Enterobacter, Citrobacter, and Pseudomonas species showed high resistance to several antibiotics. No significant between-group differences were found in the duration of hospitalization, in-hospital mortality rates due to cholangitis, and rates of increased disease severity. However, the rate of post-ERCP cholecystitis was significantly higher in the antibiotic-resistant group than in the antibiotic-sensitive group (p=0.0245).

Conclusions

Even if the initial antibiotics were ineffective, the rate of fatal outcomes did not increase among patients with cholangitis who had undergone early ERCP. However, when initial antibiotics were ineffective, the frequency of post-ERCP cholecystitis increased even after early bile duct decompression.

ASGE guideline on the management of cholangitis

Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention (<48 hours vs >48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.

Risk Factors for Acute Cholangitis Caused by Enterococcus faecalis and Enterococcus faecium

Background/Aims

Acute cholangitis (AC) is a potentially life-threatening bacterial infection, and timely antimicrobial treatment, faster than that achieved with bacterial cultures, is recommended. Although the current guidelines refer to empirical antimicrobial treatment, various kinds of antimicrobial agents have been cited because of insufficient analyses on the spectrum of pathogens in AC. Enterococcus spp. is one of the most frequently isolated Gram-positive bacteria from the bile of patients with AC, but its risk factors have not been extensively studied. This study aimed to analyze the risk factors of AC caused by Enterococcusfaecalis and Enterococcusfaecium.

Methods

Patients with AC who were hospitalized in a Japanese tertiary center between 2010 and 2015 were retrospectively analyzed. Patients’ first AC episodes in the hospital were evaluated.

Results

A total of 266 patients with AC were identified. E. faecalis and/or E. faecium was isolated in 56 (21%) episodes of AC. Prior endoscopic sphincterotomy (EST), the presence of a biliary stent, prior cholecystectomy, and past intensive care unit admission were more frequently observed in AC patients with E. faecalis and/or E. faecium than in those without such bacteria. Prior EST was identified as an independent risk factor for AC caused by E. faecalis and/or E. faecium in the multivariate analysis.

Conclusions

Given the intrinsic resistance of E. faecalis and E. faecium to antibiotics, clinicians should consider empirical therapy with anti-enterococcal antibiotics for patients with prior EST.

Association of Timing of Biliary Drainage with Clinical Outcomes in Severe Acute Cholangitis: A Retrospective Cohort Study

Purpose

The guidelines recommend urgent biliary drainage (BD) for severe acute cholangitis, without a clear definition of “urgent”. To explore the optimal time, we identified the impact of timing of BD on clinical outcomes in severe acute cholangitis.

Patients and Methods

A retrospective study of patients with severe acute cholangitis was conducted based on the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Multivariable regressions were used to identified the effect of timing of BD on in-hospital mortality, 30-day mortality, and the length of stay (LOS) in hospital and the intensive care unit (ICU) with adjustment for confounding factors.

Results

A total of 106 severe acute cholangitis patients underwent BD with a median time of 14.14 hours (IQR: 7.60–32.59). Among them, 67.9% were performed within 24 hours and 80.2% within 48 hours. Median length of stay was 2.65 days (IQR: 1.70–5.12) in the ICU and 7.54 days (IQR: 4.49–17.17) in hospital. The in-hospital and 30-day mortality rates were 13.2% and 14.2%, respectively. On multivariate analysis, every 1-day delay of BD increased 1.49 days of stay in hospital (P<0.0001). Delayed BD (>48 hours) was linked with 5.56 days longer ICU LOS (P = 0.0096), while urgent BD (<24 hours) did not significantly shorten the ICU stay (P = 0.0997). No significant increase was observed on in-hospital mortality (OR = 1.03; 95% CI 0.93–1.13) nor 30-day mortality (OR=1.01; 95% CI 0.87–1.14) with BD delay in this population.

Conclusion

In severe acute cholangitis patients, delay in BD increased in-hospital LOS. BD after 48 hours was associated with longer ICU LOS. Yet, BD within 24 hours did not significantly reduce the mortality nor shortened the ICU LOS.

Timing of Performing Endoscopic Retrograde Cholangiopancreatography and Inpatient Mortality in Acute Cholangitis: A Systematic Review and Meta-Analysis

Although early biliary drainage improves outcomes in patients with acute cholangitis, the optimal time to perform endoscopic retrograde cholangiopancreatography (ERCP) is controversial. Our aim was to evaluate the impact of timing of ERCP on mortality in hospitalized patients with acute cholangitis.

ERCP within 6 or 12 h for acute cholangitis: a propensity score-matched analysis

BACKGROUND

The optimal timing of biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis remains controversial. The aim of our study was to determine if ERCP performed within 6 or 12 h of presentation was associated with improved clinical outcomes.

METHODS

Medical records for all patients with acute cholangitis who underwent ERCP at our institution between 2009 and 2018 were reviewed. Outcomes were compared between those who underwent ERCP within or after 12 h using propensity score framework. Our primary outcome was length of hospitalization. Secondary outcomes included in-hospital mortality, adverse events, ERCP failure, length of ICU stay, organ failure, recurrent cholangitis, and 30-day readmission. In secondary analysis, outcomes for ERCP done within or after 6 h were also compared.

RESULTS

During study period, 487 patients with cholangitis were identified, of whom 147 had ERCP within 12 h of presentation. Using propensity score matching, we selected 145 pairs of patients with similar characteristics. Length of hospitalization was similar between ERCP within or after 12 h (135.9 vs 122.1 h, p 0.094). No difference was noted in mortality, ERCP failure, adverse events, need and length of ICU stay, and recurrent cholangitis. However, 30-day readmission rates were lower when ERCP within 12 h (7.6 vs 15.2, p 0.042). No significant difference was noted in aforementioned outcomes between ERCP performed within or after 6 h.

CONCLUSIONS

ERCP performed within 6 h or 12 h of presentation was not associated with superior clinical outcomes, however, may result in reduced re-hospitalization.

Very urgent endoscopic retrograde cholangiopancreatography is associated with early discharge in patients with non-severe acute cholangitis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is a first-line procedure for biliary drainage in patients with acute cholangitis, and no study focused very urgent ERCP within several hours of hospital arrival. We aimed to elucidate the utility of very urgent ERCP for non-severe acute cholangitis.

METHODS

This retrospective observational study included patients with non-severe acute cholangitis who underwent ERCP between April 2011 and June 2020 in the study institution. Patients were stratified into three groups based on the time to ERCP after hospital arrival: very urgent (≤3hours), urgent (3-24hours), and elective (>24hours). The primary outcome was length of hospital stay (LOS).

RESULTS

In the study cohort of 291 patients, including 168 males (57.7%), with a median age of 76 (interquartile range, 70-83) years, 47, 196, and 48 patients underwent very urgent, urgent, and elective ERCP, respectively. The median LOSs in the very urgent, urgent, and elective groups were 12, 14, and, 15 days, respectively (Kaplan-Meier method). A shorter LOS was associated with earlier ERCP (log-rank trend test, P=0.04). The rates of readmission within 30 days of discharge and adverse events were not significantly different among the three groups. By multivariate analysis, very urgent ERCP was associated with a significantly earlier discharge than urgent and elective ERCP (HR 0.71, P=0.04 and HR 0.47, P<0.01, respectively). In addition, age≥75years, pancreatitis, albumin≤2.8g/dL, and two or more ERCP procedures were associated with significantly longer LOS (HRs <1, P<0.05).

CONCLUSIONS

Very urgent ERCP for non-severe acute cholangitis was associated with early discharge.

Analysis of patterns of bacteremia and 30-day mortality in patients with acute cholangitis over a 25-year period

INTRODUCTION

Acute cholangitis (AC) is a condition of bacterial infection in the biliary tract with a high mortality rate of around 10%. Direct association between presence of bacteremia and 30-day mortality among AC patients is sparsely investigated and remains unclear.

AIMS AND METHODS

Our aim was to investigate association between bacteremia and 30-day mortality among patients with AC included over a period of 25 years. All AC patients that underwent endoscopic retrograde cholangiopancreatography (ERCP) at Odense University Hospital, between 1 January 1990 and 31 October 2015, were identified using a prospective ERCP database. Blood culture results from the patients along with antimicrobial resistance patterns were collected from a bacteremia research database.

RESULTS

During the study period, 775 consecutive AC patients underwent ERCP and blood cultures were collected from 528 patients. Among these patients 48% (n = 260) had bacteremia. Overall, 30-day mortality in patients with blood cultures performed was 13% (n = 69). In patients with bacteremia, 30-day mortality was 19% (n = 49), compared to 7% (n = 20) in patients without bacteremia (p < .01). Presence of bacteremia was associated with increased 30-day mortality (OR [95% CI]: 3.43 [1.92-6.13]; p < .01) following adjustment for confounding factors. Among the species, bacteremia with Enterobacter cloacae was significantly associated with increased 30-day mortality (OR [95% CI]: 2.97 [1.16-7.62]; p = .02).

CONCLUSION

Our results indicate that presence of bacteremia was associated with a nearly fourfold increase in 30-day mortality among AC patients.

Elderly patients (≥ 80 years) with acute calculous cholangitis have similar outcomes as non-elderly patients (< 80 years): Propensity score-matched analysis

BACKGROUND

Acute cholangitis (AC) is a disease spectrum with varying extent of severity. Age ≥ 75 years forms part of the criteria for moderate (Grade II) severity in both the Tokyo Guidelines (TG13 and TG18). Aging is associated with reduced physiological reserves, frailty, and sarcopenia. However, there is evidence that age itself is not the determinant of inferior outcomes in elective and emergency biliary diseases. There is a paucity of reports comparing clinical outcomes amongst elderly patients vs non-elderly patients with AC.

AIM

To investigate the effect of age (≥ 80 years) on AC's morbidity and mortality using propensity score matching (PSM).

METHODS

This is a single-center retrospective cohort study of all patients diagnosed with calculous AC (January 2016 to December 2016) and ≥ 80 years old (January 2012 to December 2016) at a tertiary university-affiliated teaching hospital. Inclusion criteria were patients who were treated for suspected or confirmed AC secondary to biliary stones. Patients with AC on a background of hepatobiliary malignancy, indwelling permanent metallic biliary stents, or concomitant pancreatitis were excluded. Elderly patients were defined as ≥ 80 years old in our study. A 1:1 PSM analysis was performed to reduce selection bias and address confounding factors. Study variables include comorbidities, vital parameters, laboratory and radiological investigations, and type of biliary decompression, including the time for endoscopic retrograde cholangiopancreatography (ERCP). Primary outcomes include in-hospital mortality, 30-d and 90-d mortality. Length of hospital stay (LOS) was the secondary outcome.

RESULTS

Four hundred fifty-seven patients with AC were included in this study (318 elderly, 139 non-elderly). PSM analysis resulted in a total of 224 patients (112 elderly, 112 non-elderly). The adoption of ERCP between elderly and non-elderly was similar in both the unmatched (elderly 64.8%, non-elderly 61.9%, P = 0.551) and matched cohorts (elderly 68.8% and non-elderly 58%, P = 0.096). The overall in-hospital mortality, 30-d mortality and 90-d mortality was 4.6%, 7.4% and 8.5% respectively, with no statistically significant differences between the elderly and non-elderly in both the unmatched and matched cohorts. LOS was longer in the unmatched cohort [elderly 8 d, interquartile range (IQR) 6-13, vs non-elderly 8 d, IQR 5-11, P = 0.040], but was comparable in the matched cohort (elderly 7.5 d, IQR 5-11, vs non-elderly 8 d, IQR 5-11, P = 0.982). Subgroup analysis of patients who underwent ERCP demonstrated the majority of the patients (n = 159/292, 54.5%) had delayed ERCP (> 72 h from presentation). There was no significant difference in LOS, 30-d mortality, 90-d mortality, and in-hospital mortality in patients who had delayed ERCP in both the unmatched and matched cohort (matched cohort: in-hospital mortality [n = 1/42 (2.4%) vs 1/26 (3.8%), P = 0.728], 30-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], 90-d mortality [n = 2/42 (4.8%) vs 2/26 (7.7%), P = 0.618], and LOS (median 8.5 d, IQR 6-11.3, vs 8.5 d, IQR 6-15.3, P = 0.929).

CONCLUSION

Mortality is indifferent in the elderly (≥ 80 years old) and non-elderly patients (< 80 years old) with AC.

Optimal timing of endoscopic retrograde cholangiopancreatography for acute cholangitis associated with distal malignant biliary obstruction

BACKGROUND

There is a lack of studies regarding the optimal timing for endoscopic retrograde cholangiopancreatography (ERCP) in patients with cholangitis caused by distal malignant biliary obstruction (MBO). This study aims to investigate the optimal timing of ERCP in patients with acute cholangitis associated with distal MBO with a naïve papilla.

METHODS

A total of 421 patients with acute cholangitis, associated with distal MBO, were enrolled for this study. An urgent ERCP was defined as being an ERCP performed within 24 h following emergency room (ER) arrival, and early ERCP was defined as an ERCP performed between 24 and 48 h following ER arrival. We evaluated both 30-day and 180-day mortality as primary outcomes, according to the timing of the ERCP.

RESULTS

The urgent ERCP group showed the lowest 30-day mortality rate (2.2%), as compared to the early and delayed ERCP groups (4.3% and 13.5%) (P < 0.001). The 180-day mortality rate was lowest in the urgent ERCP group, followed by early ERCP and delayed ERCP groups (39.4%, 44.8%, 60.8%; P = 0.006). A subgroup analysis showed that in both the primary distal MBO group, as well as in the moderate-to-severe cholangitis group, the urgent ERCP had significantly improved in both 30-day and 180-day mortality rates. However, in the secondary MBO and mild cholangitis groups, the difference in mortality rate between urgent, early, and delayed ERCP groups was not significant.

CONCLUSIONS

In patients with acute cholangitis associated with distal MBO, urgent ERCP might be helpful in improving the prognosis, especially in patients with primary distal MBO or moderate-to-severe cholangitis.

Prognostic factors associated with six month mortality of critically ill elderly patients admitted to the intensive care unit with severe acute cholangitis

BACKGROUND

Little is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality.

METHODS

Bi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed.

RESULTS

85 patients, with a median [Q1-Q3] age of 83 [80-89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1-Q3] ICU length of stay was 3 [2-6] days. Median [Q1-Q3] admission SAPS II was 50 [42-70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4-817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5-0.9]) were associated with higher 6-month mortality.

CONCLUSION

In their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care.

TRIAL REGISTRATION

NCT03831529.

Acute cholangitis in intensive care units: clinical, biological, microbiological spectrum and risk factors for mortality: a multicenter study

Background

Little is known on the outcome and risk factors for mortality of patients admitted in Intensive Care units (ICUs) for Acute cholangitis (AC).

Methods

Retrospective multicenter study included adults admitted in eleven intensive care units for a proven AC from 2005 to 2018. Risk factors for in-hospital mortality were identified using multivariate analysis.

Results

Overall, 382 patients were included, in-hospital mortality was 29%. SOFA score at admission was 8 [5–11]. Biliary obstruction was mainly related to gallstone (53%) and cancer (22%). Median total bilirubin and PCT were respectively 83 µmol/L [50–147] and 19.1 µg/L [5.3–54.8]. Sixty-three percent of patients (n  = 252) had positive blood culture, mainly Gram-negative bacilli (86%) and 14% produced extended spectrum beta lactamase bacteria. At ICU admission, persisting obstruction was frequent (79%) and biliary decompression was performed using therapeutic endoscopic retrograde cholangiopancreatography (76%) and percutaneous transhepatic biliary drainage (21%). Adjusted mortality significantly decreased overtime, adjusted OR for mortality per year was 0.72 [0.54–0.96] (p = 0.02). In a multivariate analysis, factors at admission associated with in-hospital mortality were: SOFA score (OR 1.14 [95% CI 1.05–1.24] by point, p = 0.001), lactate (OR 1.21 [95% CI 1.08–1.36], by 1 mmol/L, p < 0.001), total serum bilirubin (OR 1.26 [95% CI 1.12–1.41], by 50 μmol/L, p < 0.001), obstruction non-related to gallstones (p < 0.05) and AC complications (OR 2.74 [95% CI 1.45–5.17], p = 0.002). Time between ICU admission and biliary decompression > 48 h was associated with in-hospital mortality (adjusted OR 2.73 [95% CI 1.30–6.22], p = 0.02).

Conclusions

In this large retrospective multicenter study, we found that AC-associated mortality significantly decreased overtime. Severity of organ failure, cause of obstruction and local complications of AC are risk factors for mortality, as well as delayed biliary drainage > 48 h.

Factors Associated with Mortality in Severe Acute Cholangitis in a Moroccan Intensive Care Unit: A Retrospective Analysis of 140 Cases

BACKGROUND

Severe acute cholangitis is a life-threatening biliary infection, leading to organ dysfunction, septic shock, and naturally death. Mortality has dropped significantly in the past years through improving resuscitation and biliary drainage techniques. The aim of our study is to analyze our daily practice and the factors associated with mortality.

METHODS

A retrospective study including severe acute cholangitis patients admitted to our unit from January 2009 to December 2018. Variables analyzed (univariate then multivariate analysis) were age, sex, history, origin, evolution time, bilirubin, etiology, organ dysfunction, qSOFA, SOFA, TOKYO, biliary drainage timing and technique, shock, antibiotherapy, and resuscitation.

RESULTS

140 patients were included in this study. Average age was 61. Sex ratio M/F was 0.59. Lithiasis etiology was dominant (69%). SOFA average score upon admission was 8. Ceftriaxone + metronidazole was the empirical antibiotic used in 87%. Average time to biliary drainage was 1.58 ± 0.89 days. Endoscopic unblocking was the technique used in 76%. Mean duration of ICU stay was 6 days. Mortality rate was 28%. Statistically significant factors for mortality (p < 0.05) were history of taking anticoagulant treatment, use of catecholamines and mechanical ventilation during ICU stay, and delay in consultation and administration of antibiotic therapy.

CONCLUSIONS

Early recognition, antibiotics, resuscitation, and minimally invasive biliary drainage have improved patient outcomes although there is still progress to be made. Moreover, as multiple organ failure is often associated with mortality in severe acute cholangitis, predictive risk factors of organ failure should be more investigated.

The efficacy and safety of one-stage endoscopic treatment for ascending acute cholangitis caused by choledocholithiasis with severe comorbidities

BACKGROUND

Emergency endoscopic retrograde cholangiopancreatography (ERCP) for ascending acute cholangitis in patients with severe comorbidities is challenging. Here, we evaluated the efficacy and safety of one-stage ERCP in such patients by performing a retrospective study.

METHODS

We included all patients with ascending acute cholangitis and undergoing ERCP between January 2017 and March 2019. In total, we recruited 212 patients: 74 and 138 with and without severe comorbidities, respectively. We collected and analyzed data related to basal characteristics, ERCP, and clinical outcomes.

RESULTS

Elderly age (76.20 ± 9.99 years vs. 66.52 ± 8.16 years, P = 0.000), higher levels of leukocyte count (15.86 ± 2.47 × 109/ml vs. 13.49 ± 1.65 × 109/ml, P = 0.000), and serum bilirubin (3.11 ± 1.29 mg/dl vs. 1.94 ± 0.90 mg/dl, P = 0.000) were present in patients with severe comorbidities. A significantly higher proportion of these patients were severe cases (32.4% vs. 6.5%, P = 0.000), American Society of Anesthesiologists (ASA) stage V status (37.8% vs. 10.1%, P = 0.000) and had undergone general anesthesia (56.8% vs. 18.8%, P = 0.000). Successful biliary cannulation and complete stone clearance in one session were achieved in 207 and 202 patients, respectively. Mean length of hospital stay was 8.02 ± 2.71 days. Forty-three patients required ICU stay with the mean length of 3.26 ± 3.51 days. In-hospital mortality occurred in seven patients; all these patients had severe comorbidities. ERCP details, including urgent and early ERCP, biliary cannulation, complete stone clearance in one session, stent insertion, and complications were not significantly different between the two groups. Patients with severe comorbidities had a longer in-hospital stay (9.39 ± 3.15 days vs. 7.29 ± 2.11 days, P = 0.000), a higher proportion of ICU admission (45.9% vs. 6.5%, P = 0.000), and a longer ICU stay length (4.88 ± 4.37 days vs. 1.44 ± 0.52 days, P = 0.000). Our data also revealed that early diagnosis is an important predictor associated with clinical outcomes.

CONCLUSIONS

One-stage ERCP is safe and effective for ascending acute cholangitis caused by choledocholithiasis. Early diagnosis is a significant predictor of clinical outcomes.

National trends and outcomes in timing of ERCP in patients with cholangitis

INTRODUCTION

Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis.

METHODS

The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk.

RESULTS

Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001).

CONCLUSION

There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.

Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis

BACKGROUND AND AIMS

Acute cholangitis is characterized by abdominal pain, fever, and jaundice. Most patients respond to medical management with intravenous hydration and antibiotics. About 20% to 30% require biliary drainage, and ERCP is the procedure of choice. We conducted a systematic review and meta-analysis to evaluate the impact of emergent biliary drainage on patient outcomes.

METHODS

A comprehensive literature review was conducted by searching the Embase and PubMed databases from inception to April 2019 to identify all studies that evaluated the impact of timing of ERCP on patient outcomes. Our primary outcome was in-hospital mortality (IHM), and secondary outcomes were length of stay (LOS), organ failure, and 30-day mortality. Fixed and random effects models were used to generate pooled measures of IHM, 30-day mortality, and LOS.

RESULTS

Nine observational studies involving 7534 patients were included in the primary meta-analysis. IHM was significantly lower in patients who underwent emergent biliary drainage within 48 hours (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.28-0.98). As a sensitivity analysis, we pooled the data from 2 population registry studies of 81,893 patients, which yielded consistent results for the main outcomes. LOS was also significantly lower in patients who underwent ERCP within 48 hours with a mean difference of 5.56 days (95% CI, 1.59-9.53). Patients who underwent emergent ERCP also had lower odds of 30-day mortality (OR, 0.39; 95% CI, 0.14-1.08) and organ failure (OR, 0.69; 95% CI, 0.33-1.46).

CONCLUSIONS

Our study reveals that performing emergent ERCP within 48 hours in patients with acute cholangitis is associated with lower IHM, 30-day mortality, organ failure, and shorter LOS.

Risk Factors for the Development of Stent-Associated Cholangitis Following Endoscopic Biliary Stent Placement

BACKGROUND AND AIM

To elucidate the overall risk and risk factors for developing cholangitis following biliary stent placement by endoscopic retrograde cholangiopancreatography (ERCP) and to determine the clinical outcomes of these individuals.

METHODS

We performed a retrospective review of 796 patients who had undergone 1127 ERCPs with biliary stent placement between 2007 and 2015 at a single tertiary care center. There were 91 episodes of stent-associated cholangitis (SAC) during the study period. Data obtained through the medical records included ERCP indication, patient factors (biliary anatomy, demographics, and comorbidities), stent characteristics (material, length, and design), change in serum bilirubin, stent indwelling time, rates and etiologies of bacteremia, and the mortality rate.

RESULTS

Those with SAC were more likely to have an anatomic biliary stricture (13.1% vs. 2.3%, p < .0001), with hilar and multiple strictures having the highest risk (19.1% vs. 11.6%, p = .04). The ERCP indication of malignant biliary obstruction was associated with higher rates of SAC (15.6% vs. 3.4%, p = < .0001). Rates of SAC were higher in those who failed to normalize total bilirubin (16.9% vs. 7.8%, p = .0005), and these episodes occurred earlier compared to those who normalized total bilirubin (median 30.5 days vs. 140.5 days, p < .0001).

CONCLUSIONS

Patients at increased risk of SAC include those with an anatomic stricture, malignant biliary obstruction, and those who fail to normalize total bilirubin after biliary stent placement. Future protocols should be designed to reduce the risk of cholangitis in these populations.

Unchanged mortality in patients with acute cholangitis despite an increase in malignant etiologies - a 25-year epidemiological study

Background and aims: Acute cholangitis (AC) is a rare but serious condition, with an incidence of 7.0 per 10,000 people and mortality rates up to 10%. The aim of this study was to describe changes in obstruction etiology, comorbidities, clinical factors, and mortality among AC patients during a 25-year period. Methods: Using a database of 11,563 consecutive ERCP-procedures performed from 1990-2015 at Odense University Hospital, we identified all AC cases during that period. Clinical and epidemiological data were collected from the database and the Danish Patient Registry. Association with 30-day mortality was investigated using multiple logistic regression analysis with adjustment for confounding factors. Results: In total, 775 consecutive and individual cases of AC were included. Among cases, 42% (n = 326) were of malignant etiology, with an increasing incidence over time (regression coefficient [95% CI]: 0.03 [0.01-0.04] per year; p = .01). Mean Charlson Comorbidity Index was 1.4, with an increase over time (regression coefficient [95% CI]: 0.04 [0.03-0.05] per year; p < .01). Malignant obstruction etiology was associated with 30-day mortality (OR [95% CI]: 1.11 [1.04-1.18]; p < .01). Overall 30-day mortality was 12% (n = 91). After adjustment for confounding factors, no significant changes in 30-day mortality were observed over time (OR [95% CI]: 1 [1-1.00]; p = .91 per year). Conclusion: Significant increases in the incidence of malignant obstruction etiology and severity of comorbidities among AC patients were observed during the study period. Despite those findings, 30-day mortality remained unchanged, potentially reflecting a general improvement in the management of AC.

Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: A nationwide analysis

AIM

To assess the effect of early vs late endoscopic retrograde cholangiopancreatography (ERCP) on mortality and readmissions in acute cholangitis, using a nationally representative sample.

METHODS

We used the 2014 National Readmissions Database to identify adult patients hospitalized with acute cholangitis who underwent therapeutic ERCP within one week of admission. Early ERCP was defined as ERCP performed on the same day of admission or the next day (days 0 or 1, < 48 h), and late ERCP was performed on days 2 to 7 of admission. Patients with severe cholangitis had any of the following additional diagnoses: Severe sepsis, septic shock, acute renal failure, acute respiratory failure, or thrombocytopenia. 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.

RESULTS

Four thousand five hundred and seventy patients satisfied the inclusion criteria; with a mean age of 64.1 years. Of these, 66.6% had early ERCP, while 33.4% had late ERCP. Early ERCP was associated with lower in-hospital mortality [1.2% vs 2.4%, adjusted odds ratio (aOR) = 0.50, 95%CI: 0.76-0.83, P = 0.001] and lower 30-d mortality (1.5% vs 3.3%, aOR = 0.48, 95%CI: 0.33-0.69, P < 0.0001) compared to the late ERCP group. Similarly, early ERCP was associated with lower 30-d readmissions (9.7% vs 15.1%, aOR = 0.58, 95%CI: 0.49-0.7, P < 0.0001). When stratified by severity of cholangitis, there was a similar benefit of early ERCP on all outcomes in those with and without severe cholangitis. The mean length of stay was higher in the late ERCP group compared to the early ERCP group (6.9 d vs 4.5 d, P < 0.0001). The mean hospitalization cost was higher in the late ERCP group ($21459 vs $16939, P < 0.0001).

CONCLUSION

Early ERCP is associated with lower in-hospital and 30-d mortality in those with or without severe cholangitis. Regardless of severity, we suggest performing early ERCP.

Diagnostic value of elevated serum carbohydrate antigen 199 level in acute cholangitis secondary to choledocholithiasis

AIM

To investigate the diagnostic value of abnormal serum carbohydrate antigen 199 (CA199) level in acute cholangitis secondary to choledocholithiasis.

METHODS

In this retrospective cohort study, the clinical data of 727 patients with choledocholithiasis admitted to the Third Affiliated Hospital of Zunyi Medical College from June 2011 to June 2017 were collected. Among these patients, 258 patients had secondary acute cholangitis and served as observation group, and the remaining 569 choledocholithiasis patients served as the control group. Serum liver function indexes and tumor markers were detected in both groups, and the receiver operating characteristic (ROC) curves were constructed for markers showing statistical significances. The cutoff value, sensitivity, and specificity of each marker were calculated according to the ROC curves.

RESULTS

The results of liver function tests showed no significant differences between the two groups (P > 0.05). Tumor markers including serum CA125, CA153, carcinoembryonic antigen, and alpha fetoprotein levels were also not significantly different (P > 0.05); however, the serum CA199 level was significantly higher in the observation group than in the control group (P < 0.05). The ROC curve analysis showed that the area under the curve was 0.885 (95%CI: 0.841-0.929) for CA199, and the cutoff value of 52.5 kU/L had the highest diagnostic accuracy, with a sensitivity of 86.8% and a specificity of 81.6%.

CONCLUSION

Abnormally elevated serum CA199 level has an important value in the diagnosis of acute cholangitis secondary to choledocholithiasis. It may be a specific inflammatory marker for acute cholangitis.

No Association of Timing of Endoscopic Biliary Drainage with Clinical Outcomes in Patients with Non-severe Acute Cholangitis

BACKGROUND

Biliary drainage via endoscopic retrograde cholangiopancreatography (ERCP) is the first-line treatment for acute cholangitis. Despite the established effectiveness of urgent biliary drainage in patients with severe acute cholangitis, the indication of this procedure for non-severe acute cholangitis is controversial.

AIMS

To assess the safety of elective drainage (≥ 12 h of admission) for non-severe acute cholangitis.

METHODS

We retrospectively identified 461 patients with non-severe acute cholangitis who underwent endoscopic biliary drainage. Using linear regression models with adjustment for a variety of potential confounders, we compared elective versus urgent biliary drainage (< 12 h of admission) in terms of clinical outcomes. The primary outcome was the length of stay.

RESULTS

There were 98 and 201 patients who underwent elective and urgent biliary drainage, respectively. The median length of stay was 11 days in both groups (P = 0.52). The timing of ERCP was not associated with length of stay in the multivariable model (P = 0.52). Secondary outcomes including in-hospital mortality and recurrence of cholangitis were not different between the groups.

CONCLUSIONS

Elective biliary drainage was not associated with worse clinical outcomes of non-severe acute cholangitis as compared to urgent drainage. Further investigation is warranted to justify the elective drainage for non-severe cholangitis.

Early biliary drainage is associated with favourable outcomes in critically-ill patients with acute cholangitis

Introduction

Acute cholangitis (AC) is a clinical condition that requires prompt medical management with IV fluids, antibiotics, and biliary drainage (BD). The optimal timing for BD remains unclear.

Aim

To investigate the effect of biliary drainage timing on clinical outcomes in AC.

Material and methods

We conducted a retrospective study of patients with AC admitted to the ICU using the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Emergency department to BD time, hospital death, length of stay (LOS), and severity scores were extracted from the database. We investigated the effect of BD timing on mortality rates, persistent organ failure, and LOS.

Results

A total of 177 patients were included; 50% were males; median age was 75 years, in-hospital mortality was 9.6%, mean time-to-ERCP was 32 h (range: 0.42–229.6) with 76% meeting the Tokyo Guidelines (TG13) criteria for severe cholangitis, and median Simplified Acute Physiology Score II (SAPS II) was 42 (IQR: 33–51). Using 24 h as a cut-off, patients who underwent BD ≤ 24 h had less persistent organ failure (OR = 0.49; 95% CI: 0.26–0.96, p = 0.040), shorter ICU LOS (3.25 vs. 4.95 days, p = 0.040), shorter hospital LOS (7.71 vs. 13.57 days, p = 0.001), but no difference in either in-hospital mortality (OR = 0.47, 95% CI: 0.17–1.29, p = 0.146) or 28-day mortality (OR = 0.61, 95% CI: 0.24–1.53, p = 0.297).

Conclusions

In critically-ill patients with acute cholangitis, early biliary drainage ≤ 24 h is associated with less persistent organ failure and shorter length of stay but had no effect on patient survival.

Worsening of Acute Cholangitis Caused by a Bile Duct Stone After Hospitalization: A Case Series

Acute cholangitis is a fatal condition if inadequately treated. It is possible to underestimate the severity of the condition because bacterial cultures are not immediately available. We evaluated the clinical features of patients with cholangitis due to bile duct stones who were diagnosed with severe bacteremia at the time of hospitalization, but not at the time of the initial visit. We conducted a retrospective analysis of cases of endoscopic retrograde cholangiopancreatography performed between January 2007 and October 2011 in patients with bile duct stones complicated by cholangitis. The severity of cholangitis was assessed based on the 2005 Japanese Evidence-Based Practice Guidelines for the Management of Acute Cholangitis and Cholecystitis (JG05). Of 130 cases, 23 were diagnosed as severe cholangitis, including 11 of bacterial cause. However, based on the JG05, two cases were classified as “mild” at initial assessment and nine cases as “moderate”. A history of endoscopic sphincterotomy (EST) was identified in the two cases classified as “mild” cholangitis. Obstruction by a bile duct stone, possibly due to reflux from the duodenum, can lead to rapid progression to sepsis in a short time. For patients with a history of EST, early biliary drainage is necessary to prevent rapid progression of bacterial cholangitis.

Association between early ERCP and mortality in patients with acute cholangitis

BACKGROUND AND AIMS

Acute cholangitis (AC) is associated with high mortality of up to 10%. The association between timing of ERCP and mortality in patients with AC remains unclear. The aim of this study was to investigate whether early ERCP within 24 hours was associated with improved survival.

METHODS

All patients who underwent ERCP at Odense University Hospital, Denmark, between March 2009 and September 2016 were identified using a prospective ERCP database. Clinical data were collected from medical records. Patients fulfilling the Tokyo Guidelines 2013 criteria and for whom a detailed review of medical records revealed evidence of AC were included. We investigated the association between ERCP within 24 hours and 30-day mortality using logistic regression analysis with adjustment for confounding factors.

RESULTS

A total of 4066 consecutive patients underwent ERCP during the study period, and 166 patients fulfilled the inclusion criteria. Forty-eight patients (29%) underwent ERCP within 24 hours from the time of hospitalization, and 118 patients (71%) underwent later ERCP. Patients undergoing ERCP within 24 hours were younger (medians: 65 vs 73 years; P = .01) and had a higher heart rate (medians: 95 vs 90 beats/minute; P = .02). Overall 30-day mortality was 16% (n = 27). Mortality was 8% (n = 4) among patients undergoing early ERCP and 19% (n = 23) among patients undergoing later ERCP (P = .10). After adjustment for confounding factors, performance of ERCP within 24 hours was associated with lower 30-day mortality (odds ratio, 0.23; 95% confidence interval, 0.05-0.95; P = .04).

CONCLUSION

Our results indicate that early ERCP within 24 hours is associated with lower 30-day mortality in patients with AC.

Predictors and outcomes of delayed plastic biliary stent removal following endoscopic retrograde cholangiopancreatography

OBJECTIVE

Plastic biliary stents are commonly placed during endoscopic retrograde cholangiopancreatography (ERCP) and should be removed or replaced within 3 months to reduce the risk of stent obstruction. The aim of the study was to identify predictors and outcomes of patients who had delayed plastic biliary stent removal following ERCP.

MATERIALS AND METHODS

Consecutive patients who received ERCP with plastic biliary stent placement at Loma Linda University Medical Center (10/2004-6/2013) were identified. Delayed removal was defined as presence of stent >3 months after index ERCP. Multivariable regression analysis to identify baseline characteristics associated with delayed removal was performed. Clinical outcomes of stent obstruction (e.g., cholangitis, hospitalization, intensive care) were also collected for those with delayed removal.

RESULTS

Among 374 patients undergoing ERCP with plastic biliary stent, 71 (19%) had delayed stent removal. Patients who had anesthesia assistance (AOR = 3.8, 95%CI 1.2-11.4), non-English primary language (AOR = 3.0, 95%CI 1.5-6.2), and outpatient ERCP (AOR = 2.0, 95%CI 1.1-3.4) had increased while choledocholithiasis (AOR = 0.5, 95%CI 0.3-0.99) had lower odds of delayed stent removal. Among those with delayed removal, 13 (18%) were hospitalized for stent obstruction (5 (7%) had cholangitis, 8 (11%) were hospitalized for more than a week, and 3 (4%) required intensive care).

CONCLUSIONS

Almost one-fifth of patients who underwent ERCP with plastic biliary stent placement had delayed removal with nearly one-fifth of these patients requiring hospitalization for stent obstruction. Targeting patients at risk by improving communication and ease of scheduling an ERCP may reduce preventable adverse events associated with delayed biliary stent removal.

Current strategies for endoscopic management of acute cholangitis

BACKGROUND AND AIM

At the pancreatobiliary session of Endoscopic Forum Japan (EFJ) 2016, current strategies for the endoscopic management of acute cholangitis were discussed. The topics consisted of two major parts, namely endoscopic management of acute cholangitis caused by common bile duct stones (CBDS) and biliary stent occlusion.

METHODS

Endoscopists from nine Japanese high-volume centers along with two overseas centers participated in the questionnaires and discussion.

RESULTS

Strategies for management of cholangitis due to CBDS were agreed upon, and the clinical guideline of acute cholangitis (Tokyo guidelines 2013) was accepted. The best timing for drainage in Grade 2 (moderate) cholangitis urgent or early (<24 h) was inconclusive, and more data is required on this issue. Another controversy was the feasibility of one step stone extraction in the patient with cholangitis vs stone removal after the cholangitis had resolved. There were various opinions with regards to the management of acute cholangitis due to stent occlusion, and the strategies differed according to the stricture location (distal or hilar) and stent type initially placed (Covered or uncovered metal stent).

CONCLUSION

Strategies for management of cholangitis caused by CBD stones are well established according to the TG13. More evidence is required before further recommendations can be made with regards to cholangitis due to stent occlusion. We aim to clarify this in the near future with questionnaires and consensus from experts.