Cholangitis is a potentially serious infection of the bile ducts, the treatment of which relies on appropriate antibiotic therapy and rapid biliary decompression, primarily achieved by endoscopic retrograde cholangiopancreatography (ERCP). Among the possible complementary procedures during ERCP, bile aspiration for bacteriological analysis can be performed. However, this procedure remains underutilized and is not always systematically included in international guidelines due to a lack of robust data on its clinical impact. The objective of this study is to evaluate the clinical benefit of bile aspiration performed during ERCP in the treatment of cholangitis.

This retrospective, descriptive, single-center study was conducted within the Hepatology and Gastroenterology Department "Medicine B" of the Ibn Sina University Hospital in Rabat, covering a period of 2 years and 10 months, from January 2023 to October 2025. The medical records of patients treated by ERCP with biliary aspiration for acute cholangitis in the interventional endoscopy unit were collected and analyzed. Demographic, clinical, paraclinical, therapeutic, and outcome data were collected and analyzed.

A total of 90 patients who underwent ERCP with biliary aspiration for cholangitis were included. The mean age was 52 years [22–82], with a slight female predominance (56.7%). Twelve patients (13.3%) had previously undergone ERCP, and 10 patients (11.11%) had a biliary stent. The severity of cholangitis, assessed using the Tokyo score, was distributed as follows: grade I in 20 cases (22.2%), grade II in 53 cases (58.9%), and grade III in 17 cases (18.9%). The mean total bilirubin level was 172.1 mg/L before ERCP and decreased to 95.4 mg/L 48 hours after the procedure. The indications for ERCP were distributed as follows: neoplastic causes in 42 cases (46.7%), lithiasis in 37 cases (41.1%), and other etiologies in 11 cases (12.2%). Empirical antibiotic therapy was primarily based on a combination of third-generation cephalosporins and metronidazole, prescribed in 80 cases (88.8%). Biliary aspiration revealed a positive culture in 53 cases (58.9%) (Table 1) , with Escherichia coli and Pseudomonas spp . as the predominant pathogens (Table 2) , identified in 13 cases (24.5%) and 12 cases (22.6%), respectively. Among the positive samples, the bacteria were susceptible to empirical antibiotic therapy in 30 cases (56.6%). In cases of resistance, a change of antibiotic was necessary in 18 patients ( 33.9%) , while 5 ( 9.4%) progressed favorably without any change in treatment. The average length of hospital stay was 11.0 days. The 30-day recurrence rate was 4.5%, and the mortality rate was 4.5%.

Biliary aspiration during ERCP is a valuable tool for identifying pathogens and tailoring antibiotic therapy, particularly in the context of increasing antibiotic resistance. This study highlights its clinical value in optimizing microbiological management and improving therapeutic outcomes for patients with cholangitis.