Real-world Outcomes of Emergency ERCP in Acute Cholangitis
Experience from a Tertiary Care Centre in North India
Abstract
Background: Acute cholangitis is a potentially life-threatening condition caused by biliary obstruction and infection. Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice; however, optimal timing and strategy, especially in severe (grade III) disease, remain critical. This study evaluated the clinical spectrum, ERCP strategies, and short-term outcomes of patients with acute cholangitis at a tertiary care centre in North India.
Methods: This prospective observational study included 50 patients undergoing ERCP at the Department of Gastroenterology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, over six months from September 2024. Demographic, clinical, radiological, and microbiological parameters were recorded. ERCP timing, intervention type (upfront biliary stenting vs ductal clearance), and outcomes were assessed using Tokyo Guidelines 2018 severity grading. Early ERCP was defined as ≤24 hours from presentation.
Results: Mean age was 57.9 ± 14.0 years, with female predominance (52%). Most patients were 51–70 years old (62%) and from rural areas (76%). Severity grading: grade I 36%, grade II 38%, grade III 26%. Abdominal pain (96%) and fever (64%) were most common. Choledocholithiasis accounted for 84% of cases; malignancy 10%, benign strictures 6%. Upfront biliary stenting was performed in 66%, complete CBD clearance in 34%. Early ERCP was performed in 80% of cases. Early ERCP (≤24 h) was associated with a significantly shorter hospital stay compared with delayed ERCP (2.4 ± 0.7 vs 4.6 ± 1.8 days; p = 0.01), while rates of early clinical improvement and complications were comparable. In Grade III patients, upfront stenting shortened hospital stay and improved short-term outcomes. Bile cultures were positive in 84%, with Escherichia coli in 46%. Laboratory parameters improved significantly post-ERCP (bilirubin: p = 0.001, ALP: p = 0.022, ALT: p = 0.030). Complications occurred in 4% (mild cholangitis and pancreatitis), all managed conservatively with no ERCP-related mortality. Most patients were discharged within 3 days.
Conclusion: Early ERCP is critical for rapid clinical improvement in acute cholangitis. Overall outcomes were comparable between upfront biliary stenting and immediate ductal clearance; however, in Grade III cholangitis, upfront stenting was associated with more favourable short-term outcomes, including shorter hospital stay.These findings support early, context-specific ERCP strategies in high-grade disease.
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