BILE Criteria to Assess ERCP Need in Cholangitis May Be More Sensitive, Less Cumbersome Than Others

Biliary obstruction with associated cholangitis usually is managed with the use of endoscopic retrograde cholangiopancreatography (ERCP) for stone extraction or stent decompression of the bile duct. ERCP is efficient and widely available but carries a moderate risk of adverse events. Sets of criteria (eg, Charcot, Ranson, Tokyo) used to enhance confidence that ERCP is indicated are either insufficient or cumbersome. 

From a comprehensive literature review, the authors propose the BILE criteria that may enhance the identification of patients with cholangitis. The 4 criteria of the acronym BILE are (1) Biliary imaging abnormalities (duct dilation >6 mm, strictures, choledocholithiasis) and/or intervention within 30 days (ERCP, percutaneous biliary drainage, or surgical biliary procedures); (2) Inflammatory test abnormalities, such as body temperature >100.4 degrees Fahrenheit (38 degrees Celsius), leukophilia (white blood cell count [WBC] >12), leukopenia (WBC <4), or bandemia (>10% bands); (3) Liver test abnormalities (above normal total bilirubin, aspartate aminotransferase, alanine aminotransferase, or alkaline phosphatase); and (4) Exclusion of cholecystitis and acute pancreatitis. 

The definitive diagnostic criteria were deemed to be the identification of purulent drainage or pathologic inflammation of the duct by surgery, endoscopy, or postmortem examination, perhaps accompanied by a therapeutic response to decompression and antibiotic therapy. The authors propose prospective assessment, validation, and evolution of the BILE criteria in pursuit of a maximally sensitive and specific paradigm that will optimize intervention efficiency while minimizing endoscopic risk.