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

Published:October 16, 2019DOI:https://doi.org/10.1016/j.gie.2019.09.040

      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.


      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.


      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).


      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.


      AC (acute cholangitis), CI (confidence interval), IHM (in-hospital mortality), LOS (length of stay), MD (mean difference), OR (odds ratio)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Lan Cheong Wah D.
        • Christophi C.
        • Muralidharan V.
        Acute cholangitis: current concepts.
        ANZ J Surg. 2017; 87: 554-559
        • Lipsett P.A.
        • Pitt H.A.
        Acute cholangitis.
        Surg Clin North Am. 1990; 70: 1297-1312
        • Kimura Y.
        • Takada T.
        • Kawarada Y.
        • et al.
        Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.
        J Hepatobiliary Pancreat Surg. 2007; 14: 15-26
        • Mosler P.
        Diagnosis and management of acute cholangitis.
        Curr Gastroenterol Rep. 2011; 13: 166-172
        • Takada T.
        • Strasberg S.M.
        • Solomkin J.S.
        • et al.
        TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis.
        J Hepatobiliary Pancreat Sci. 2013; 20: 1-7
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        Ann Intern Med. 2009; 151 (W64): 264-269
        • Aboelsoud M.
        • Siddique O.
        • Morales A.
        • et al.
        Early biliary drainage is associated with favourable outcomes in critically-ill patients with acute cholangitis.
        Prz Gastroenterol. 2018; 13: 16-21
        • Parikh M.P.
        • Wadhwa V.
        • Thota P.N.
        • et al.
        Outcomes associated with timing of ERCP in acute cholangitis secondary to choledocholithiasis.
        J Clin Gastroenterol. 2018; 52: e97-e102
        • Hou L.A.
        • Laine L.
        • Motamedi N.
        • et al.
        Optimal timing of endoscopic retrograde cholangiopancreatography in acute cholangitis.
        J Clin Gastroenterol. 2017; 51: 534-538
        • Lee F.
        • Ohanian E.
        • Rheem J.
        • et al.
        Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis.
        Aliment Pharmacol Ther. 2015; 42: 212-220
        • Patel H.
        • Gaduputi V.
        • Chelimilla H.
        • et al.
        Acute cholangitis: does the timing of ERCP alter outcomes?.
        JOP. 2016; 17: 504-509
        • Alper E.
        • Unsal B.
        • Buyraç Z.
        • et al.
        Sa1520 Early ERCP is safe and cost-effective in the treatment of mild to moderate acute cholangitis [abstract].
        Gastrointest Endosc. 2011; 73: AB195
        • Mulki R.
        • Shah R.
        • Qayed E.
        Early vs late endoscopic retrograde cholangiopancreatography in patients with acute cholangitis: a nationwide analysis.
        World J Gastrointest Endosc. 2019; 11: 41-53
        • Tan M.
        • Schaffalitzky de Muckadell O.B.
        • Laursen S.B.
        Association between early ERCP and mortality in patients with acute cholangitis.
        Gastrointest Endosc. 2018; 87: 185-192
        • Jang S.E.
        • Park S.W.
        • Lee B.S.
        • et al.
        Management for CBD stone-related mild to moderate acute cholangitis: urgent versus elective ERCP.
        Dig Dis Sci. 2013; 58: 2082-2087
        • Park C.S.
        • Jeong H.S.
        • Kim K.B.
        • et al.
        Urgent ERCP for acute cholangitis reduces mortality and hospital stay in elderly and very elderly patients.
        Hepatobiliary Pancreat Dis Int. 2016; 15: 619-625
        • Kiriyama S.
        • Takada T.
        • Hwang T.-L.
        • et al.
        Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study.
        J Hepatobiliary Pancreat Sci. 2017; 24: 329-337
        • Chak A.
        • Cooper G.S.
        • Lloyd L.E.
        • et al.
        Effectiveness of ERCP in cholangitis: a community-based study.
        Gastrointest Endosc. 2000; 52: 484-489
        • Khashab M.A.
        • Tariq A.
        • Tariq U.
        • et al.
        Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis.
        Clin Gastroenterol Hepatol. 2012; 10: 1157-1161
        • Navaneethan U.
        • Njei B.
        • Hasan M.K.
        • et al.
        Timing of ERCP and outcomes of patients with acute cholangitis and choledocholithiasis: a nationwide population based study [abstract].
        Gastrointest Endosc. 2015; 81: AB354
        • Navaneethan U.
        • Gutierrez N.G.
        • Jegadeesan R.
        • et al.
        Delay in performing ERCP and adverse events increase the 30-day readmission risk in patients with acute cholangitis.
        Gastrointest Endosc. 2013; 78: 81-90
        • Inamdar S.
        • Sejpal D.V.
        • Ullah M.
        • et al.
        Weekend vs. weekday admissions for cholangitis requiring an ERCP: comparison of outcomes in a national cohort.
        Am J Gastroenterol. 2016; 111: 405-410
        • Tabibian J.H.
        • Yang J.D.
        • Baron T.H.
        • et al.
        Weekend admission for acute cholangitis does not adversely impact clinical or endoscopic outcomes.
        Dig Dis Sci. 2016; 61: 53-61
        • Hakuta R.
        • Hamada T.
        • Nakai Y.
        • et al.
        No association of timing of endoscopic biliary drainage with clinical outcomes in patients with non-severe acute cholangitis.
        Dig Dis Sci. 2018; 63: 1937-1945

      Linked Article

      • ERCP for acute cholangitis: timing is everything
        Gastrointestinal EndoscopyVol. 91Issue 4
        • Preview
          Since first described by Jean-Martin Charcot, French neurologist and Professor of Anatomical Pathology in Hôpital Salpêtrière in Paris, in the late 1800s, acute cholangitis remains well recognized by its eponymous sine qua non of fever, abdominal pain, and jaundice caused by biliary stasis and bacteriobilia.1 However, although the clinical manifestations still define the illness in most patients, the management of cholangitis has radically evolved from a disease treated primarily by surgery in the 19th century to one in which today, ERCP is widely accepted as the treatment of choice in establishing biliary drainage and often removing the cause.
        • Full-Text
        • PDF