TOPLINE

In patients with mild-to-moderate cholangitis, urgent endoscopic retrograde cholangiopancreatography (ERCP) performed within 24 hours did not reduce 30-day mortality or organ failure compared with early ERCP performed within 24-48 hours. Urgent ERCP was associated with a higher rate of adverse post-ERCP events, particularly hemorrhage.

METHODOLOGY

• Acute cholangitis has been recognized as a common gastrointestinal emergency linked to substantial morbidity and mortality. Current guidelines recommend performing ERCP within 48 hours for biliary drainage; however, this recommendation is supported by low-quality evidence, and the optimal timing within the 48-hour window remains uncertain.
• Researchers conducted a randomized controlled trial at a tertiary referral center in India between 2023 and 2024 to evaluate the clinical outcomes of urgent ERCP performed within 24 hours vs early ERCP performed within 24-48 hours in patients with mild-to-moderate acute cholangitis.
• They enrolled 304 patients diagnosed with definitive or suspected acute cholangitis according to the Tokyo Guidelines 2018 who presented with obstructive jaundice, defined by a total bilirubin level ≥ 2.5 mg/dL, an alkaline phosphatase level greater than 1.5 times the upper limit of normal, and a dilated bile duct on cross-sectional imaging.
• Participants were randomly assigned to undergo either urgent ERCP within 24 hours (n = 152; age, 55.07 years; 72.4% male; mean time to ERCP, approximately 13 hours) or early ERCP within 24-48 hours (n = 152; age, 56.09 years; 71.1% male; mean time to ERCP, approximately 33 hours).
• The primary outcome was all-cause mortality within 30 days; secondary outcomes included organ failure on days 3 and 30, in-hospital mortality, the length of hospital stay, reintervention rates, readmission rates, and post-ERCP adverse events.

TAKEAWAY

• All-cause mortality within 30 days did not differ significantly between the urgent and early ERCP groups (P = .47).
• Similarly, no significant differences were observed between the groups in terms of in-hospital mortality, organ failure on days 3 and 30, length of hospital stay, and 30-day readmission and reintervention rates.
• In the unadjusted analysis, urgent ERCP was associated with a more than twofold higher risk for adverse events than early ERCP (relative risk, 2.03; nominal P = .042). Post-ERCP hemorrhage was the most common adverse event and occurred more frequently among patients undergoing urgent ERCP (10.5% vs 3.3%).
• Multivariate analysis revealed that urgent ERCP and biliary sphincterotomy were independent predictors of post-ERCP adverse events and post-ERCP hemorrhage (P < .05 for all).

IN PRACTICE

“Our findings support a more tailored approach for stable patients with mild-to-moderate cholangitis. Rather than rushing to perform ERCP within 24 hours, careful clinical assessment and optimization, including adequate fluid resuscitation, correction of coagulopathy if present, and antibiotic therapy, may be equally effective and potentially safer,” the authors of the study wrote.

SOURCE

The study was led by Nitin Jagtap, MD, Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, India. It was published online in Gut.

LIMITATIONS

Only cases of mild and moderate acute cholangitis were included. Blood and bile culture data, along with antibiotic administration data, were not systematically collected or analyzed. The trial was conducted at a single high-volume tertiary center with specialized expertise and infrastructure, potentially limiting the generalizability of the findings to resource-limited settings with restricted access to ERCP.

DISCLOSURES

Institutional support was provided by the Asian Healthcare Foundation, Hyderabad, India. The authors declared having no relevant competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.