Endoscopic management strategies in relation to the severity of acute cholangitis

Background and Study Aims: Acute cholangitis (AC) and especially. suppurative cholangitis due to biliary lithiasis is an emergency situation that requires urgent biliary decompression. The aim of the study is to present our policy for the treatment of AC due to choledocholithiasis, endoscopically. Methods: In a 4-year period, 71 patients presenting AC, due to lithiasis, underwent endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy (ES). All patients had fever, jaundice, abdominal pain, and in case of suppurative cholangitis hemodynamic instability. Most of them seemed to be high-risk candidates for surgery. Results: Forty-nine patients had AC and 22 patients had acute obstructive suppurative cholangitis (AOSC). ES (conventional or needle-knife biliary fistulotomy) was successful in 69 out of 71 (97%) patients. Two patients were eventually operated and were excluded from statistical analysis. Fifty of the 69 patients (72%) had a complete bile duct clearance in 1 session. Conventional ES, complete bile duct clearance, and other endoscopic maneuvers (balloon, basket, lithotripsy) were significantly more frequent in the AC group (P<0.001). Needle-knife biliary fistulotomy, and stent insertion were significantly more frequent in the AOSC group (P < 0.001). Endoscopical treatment had low morbidity and total hospital stay time. Conclusions: ES is the procedure of choice for the treatment of AC offering definite treatment with low morbidity and short hospitalization. Urgent biliary decompression with minimal endoscopic maneuvers is crucial for the outcome of patients having AOSC.