Diagnostic and Therapeutic Value of ERCP in Acute Severe Cholangitis: Experience of a Moroccan Endoscopic Center

Abstract

Severe cholangitis is an urgent indication for endoscopic treatment, represented by endoscopic retrograde pancreatography (ERCP) and endoscopic sphincterotomy. It ensures good bile drainage, and improves patient morbidity and mortality. Materials and methods: This is a retrospective study carried out within our department between January 2010 and April 2018. All patients with severe cholangitis who benefited from therapeutic ERCP were enrolled. We analyzed the epidemiological data of the patients, the results of the ERCP, as well as the post-sphincterotomy mortality. We also performed multivariate analysis for predictive factors for mortality. Results: 88 patients were enrolled. The average age of the patients was 60.14 years [17-102 years], with a female predominance (n = 45, 51.1%). Twelve patients (13.6%) underwent a cholecystectomy. Almost 68, 18% patients (n = 60) had obstructive choledocholithiasis, fifteen patients (17,04%) had o cyst hydatic and 13 patients (14,77%) had tumor obstruction. Successful catheterization of the main bile duct was reported in 60 patients (68.18%), and failure in 28 cases (31.81%). The use of precut was performed in 28 cases (31.81%), which enabled successful access to main bile duct in 24 patients (85.71%). Failure of catheterization after a precut concerned 4 patients (14.28%): 3 patients (75%) benefited from a resumption of ERCP with success, and only one patient (25%) was proposed for surgery. fifty-five patients (91,66%) underwent stone evacuation (Figure 1). For 5 patients (8, 33%), failure of stone extraction was followed by successful surgery. Twenty-one patients benefited from successful implementation of a biliary prosthesis were objectified in 21 patients (25%). 5 patients (23.80%) failed. Among them, percutaneous drainage was done 4 patients (80%) and 1 patient (20%) was operated. The main post-ERCP complications were represented by: 5 cases (5.7%) of papillary bleeding, and 1 case of acute pancreatitis. The overall death rate was 11,36% (n=10). The course was marked by clinical and biological remission in the other patients with successful endoscopic drainage. The main predictors of mortality in multivariate analysis were impaired of consciousness upon admission (p = 0.023, OR=4, 5678 [2,678‑10, 7890]), and the presence of renal failure (p = 0.001, OR=6, 4809 [2,089‑15,781]). Conclusion: Endoscopic treatment is the gold standard for the treatment of severe cholangitis. Its results are satisfactory, with a lower mortality compared to surgical treatment with fewer hospitalizations.