Endoscopic management of acute cholangitis in elderly patients

Abstract

To evaluate clinical presentation, etiology, complications and response to treatment in elderly patients with acute cholangitis. Demographics, etiology of biliary obstruction, clinical features, complications and associated systemic diseases of 175 patients with acute cholangitis were recorded. Endoscopic biliary drainage was performed using nasobiliary drain or stent. The complications related to ERCP, success of biliary drainage, morbidity, mortality and length of hospital stay were evaluated. Of 175 patients, 52 aged >or=60 years (group I, age<60 years; group II, age>or=60 years) and 105 were men. Fever was present in 38 of 52 patients of group II compared to 120 of 123 in group I. High fever (fever >or=38.0 degrees C) was more common in group I (118/120 vs 18/38). Hypotension (5/123 vs 13/52), altered sensorium (3/123 vs 19/52), peritonism (22/123 vs 14/52), renal failure (5/123 vs 14/52) and associated comorbid diseases (4/123 vs 21/52) were more common in group II. Biliopancreatic malignancy was a common cause of biliary obstruction in group II (n=34) and benign diseases in group I (n=120). Indications for biliary drainage were any one of the following either singly or in combination: a fever of >or=38.0 degrees C (n=136), hypotension (n=18), peritonism (n=36), altered sensorium (n=22), and failure to improve within 72 h of conservative management (n=22). High grade fever was more common indication of biliary drainage in group I and hypotension, altered sensorium, peritonism and failure to improve within 72 h of conservative management were more common indications in group II. Endoscopic biliary drainage was achieved in 172 patients (nasobiliary drain: 56 group I, 24 group II, stent: 64 group I, 28 group II) without any significant age related difference in the success rate. Abdominal pain, fever, jaundice, hypotension, altered sensorium, peritonism and renal failure improved after median time of 5 d in 120 patients in group I (2-15 d) compared to 10 d in 47 patients of group II (3-20 d). Normalization of leucocyte count was seen after a median time of 7 d (3-20 d) in 120 patients in group I compared to 15 d (5-26 d) in 47 patients in group II. There were no ERCP related complications in either group. Five patients (carcinoma gallbladder n=3, CBD stones n=2) died in group II and they had undergone biliary drainage after failure of response to conservative management for 72 h. There was a higher mortality in patients in group II despite successful biliary drainage (0/120 vs 5 /52). Length of hospital stay was longer in group II patients (16.4+/-5.6, 7-30 d) than in group I patients (8.2+/-2.4, 7-20 d). Elderly patients with acute cholangitis have a high incidence of severe cholangitis, concomitant medical illnesses, hypotension, altered sensorium, peritonism, renal failure and higher mortality even after successful biliary drainage.