Background: Acute cholangitis (AC) in its most severe form is associated with a high mortality rate. Most patients respond to medical management involving intravenous hydration and antibiotics, though a sizable portion require biliary drainage. Current guidelines advocate for urgent drainage depending on the severity of AC, though do not specify optimal timing. Existing literature is conflicting on when ERCP should ideally be done for AC.
Study design: Systematic review and meta-analysis.
Setting: Literature search involving PubMed, Medline, and Embase databases.
Synopsis: Nine studies with 7,534 patients were included in the final meta-analysis. Emergent ERCP was associated with a lower in-hospital mortality (IHM; odds ratio, 0.52; 95% confidence interval, 0.28-0.98) and shorter length of stay (LOS; mean difference, –2.87 days; 95% CI, –1.55 to –4.18), compared to urgent ERCP. The IHM mortality difference was true for both patients with severe AC (as defined by evidence of end-organ dysfunction) and mild-moderate AC. There was a trend toward lower 30-day mortality in patients who underwent emergent ERCP, though it did not reach statistical significance.
The studies included in the analysis were observational studies, so no causal relationship can be established. Only two of the nine studies reported outcome differences stratified by severity of presentation. Etiology of the AC was inconsistently reported amongst studies.
Bottom line: Emergent ERCP appears to be associated with reduced mortality and LOS in patients presenting with AC, though larger randomized controlled trials are needed to better delineate the optimal timing for biliary drainage in these patients.
Citation: Iqbal U et al. Emergent versus urgent ERCP in acute cholangitis: A systematic review and meta-analysis. Gastrointes Endosc. 2019 Oct 16..
Dr. Babbel is a hospitalist and assistant professor of medicine at the University of Utah, Salt Lake City.