Abstract
BACKGROUND: Early endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage is recommended for acute cholangitis based on disease severity. However, the optimal timing of ERCP remains unclear. This study aimed to evaluate the impact of urgent ERCP (≤ 24 h) on clinical outcomes in patients with common bile duct (CBD) stone-related acute cholangitis. METHODS: A retrospective cohort study was conducted among patients who underwent ERCP for acute cholangitis due to CBD stones between 2008 and 2017. Patients were categorized according to ERCP timing: urgent (≤ 24 h) and non-urgent (> 24 h). Outcomes included in-hospital mortality, organ failure at 72 h, length of hospital stay, procedure-related complications, and 30-day readmission. Propensity score matching (PSM) was applied to balance baseline characteristics, including age, sex, comorbidities, Charlson comorbidity index, and cholangitis severity according to the Tokyo Guidelines 2018. RESULTS: Among 455 eligible patients, 191 matched pairs were analyzed. The mean age was 66 ± 16 years, and 50% were male. Among them, 21.5% had severe cholangitis, 40.4% moderate, and 38.1% mild disease. Following matching, patient characteristics of the two groups were balanced, except for a higher percentage of patients with moderate cholangitis in the non-urgent group. In-hospital mortality was significantly lower in the urgent ERCP group (0.5% vs 21%; adjusted OR 0.09; 95% CI: 0.01-0.73; p = 0.024). Median hospital stay was shorter (5 vs 8 days; p < 0.001), while stone clearance rates (approximately 75%), persistent organ failure, procedural complications, and readmission were comparable between groups. Subgroup analysis revealed a mortality benefit of urgent ERCP in moderate (p < 0.01) and severe (p = 0.024) cholangitis, but not in mild cases. CONCLUSIONS: Urgent ERCP within 24 h significantly reduces in-hospital mortality and shortens hospitalization in patients with moderate to severe cholangitis due to CBD stones. These findings support early intervention as a key component of management in this population.