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Time Is of the Essence for Moderate to Severe Ascending Cholangitis

Bret T. Petersen, MD, FASGE, reviewing Iqbal U, et al. Gastrointest Endosc 2019 Oct 16.

While most patients with acute cholangitis respond to initial antibiotics and hydration, definitive biliary drainage or clearance of obstruction is required to resolve the infection in about one-quarter of patients. Studies have varied as to the urgency of intervention by ERCP. 

The authors of this meta-analysis utilized rigorous criteria to evaluate the published literature addressing patient outcomes relative to the timing of ERCP. Data from 9 studies of >7500 patients demonstrated significantly reduced in-hospital mortality (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.28-0.98), 30-day mortality (OR, 0.39; 95% CI, 0.14-1.08), organ failure (OR, 0.69; 95% CI, 0.33-1.46), and length of stay (difference, 5.56 days; 95% CI, 1.59 – 9.53) when ERCP was performed within 48 hours of patient presentation with severe and mild-to-moderate cholangitis. 

These findings were further supported by a sensitivity analysis in two population registry studies totaling 81,893 patients.

COMMENT
A similar message has been conveyed by several, but not all, studies employing highly varied criteria, assessments, and intervals. It is now clear that obstructive cholangitis warrants timely intervention, without deferral beyond 48 hours. Despite our intuition, what remains unproven is the potential benefit of even more urgent intervention, within 12 to 24 hours, for those with severe cholangitis. For the infirm or elderly patient with severe cholangitis, such urgent management should not await further trials.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.

Bret T. Petersen, MD, FASGE

CITATION(S)

Iqbal U, Khara HS, Hu Y, et al. Emergent versus urgent ERCP in acute cholangitis: a systematic review and meta-analysis. Gastrointest Endosc 2019 Oct 16. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2019.09.040)

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