Predictors of Organ Failure and Role of Early ERCP in Hospitalized Patients with Acute Cholangitis

Abstract

Purpose: Acute cholangitis is considered a medical emergency and predictors associated with organ failure are not well defined. Furthermore, the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in hospitalized patients with cholangitis is unclear. The aim of the study is to examine clinical outcomes and identify predictors associated with persistent organ failure in hospitalized patients with acute cholangitis. Methods: Consecutive hospitalized patients who received ERCP at Loma Linda University Medical Center for suspected cholangitis between 4/2005-3/2013 were identified by reviewing an internal endoscopy database. Cholangitis was defined by radiographic evidence of biliary obstruction and signs of systemic infection (fever, leukocytosis, bacteremia, and/or purulent bile drainage during ERCP). Primary outcome was persistent organ failure at >48 hours from hospitalization (≥1.5 times rise in creatinine levels from baseline values to ≥1.5 mg/dL, or need for dialysis, mechanical ventilation, and/or hypotension requiring vasopressor). Results: A total of 167 patients who underwent ERCP for indication of suspected cholangitis met the inclusion criteria. The mean age was 60±19 years; 70% were male. On presentation, 86 (51%) patients demonstrated Charcot's triad, 58 (35%) had bacteremia, and ERCP was performed at a median of 41 hours (range, 0-927 hours) from hospitalization. The cause of cholangitis included common bile duct stone in 87 (52%) patients, biliary stent dysfunction in 46 (28%), and malignant stricture in 12 (7%). Initial biliary decompression with ERCP was accomplished in all but 11 patients (7%), and 4 (2%) developed ERCP associated complications (pancreatitis in three, post-sphincterotomy bleeding in one). Clinical outcomes of the 167 patients with cholangitis are shown in Table 1. On multivariate analysis, patients with Charlson Comorbidity Index >2 (odds ratio [OR] 14.0; 95% confidence interval [CI] 2.9-69.0; P=0.001) and 1-2 (OR 6.9; 95% CI 1.3-36.9; P=0.02) compared to zero, presence of systemic inflammatory response syndrome (SIRS; OR 3.7; 95% CI 1.6-8.7; P=0.002), and ERCP performed ≥48 hours (OR 3.2; 95% CI 1.4-7.9; P=0.006) compared to <48 hours from presentation were associated with persistent organ failure.TableConclusion: Delayed performance in ERCP was associated with persistent organ failure in hospitalized patients with acute cholangitis after adjusting for medical comorbidity and SIRS. Early ERCP performed <48 hours from presentation in patients with suspected cholangitis may improve outcomes.