The cornerstone of acute cholangitis treatment is antibiotic therapy combined with biliary drainage. The Tokyo Guidelines 2018 provide severity grading criteria that help predict prognosis and identify patients requiring early biliary drainage. While mild cholangitis can often be managed initially with antibiotics alone, moderate and severe cases typically require early and emergent drainage, respectively. Our aim is to explore factors influencing the timing of ERCP in acute cholangitis and its impact on clinical outcomes.

This retrospective single-center cohort study included patients diagnosed with acute cholangitis who underwent ERCP between March 2022 and December 2024 in a tertiary hospital with ERCP. Diagnosis and severity grading were based on the Tokyo Guidelines 2018. Descriptive and statistical analyses were performed to evaluate patient characteristics, severity classification, timing to ERCP and related clinical outcomes.

A total of 145 patients underwent ERCP for acute cholangitis; 79 were female (54%) and the median age was 79 years. Based on the Tokyo 2018 criteria, 41 patients (28.3%) had grade III cholangitis, 60 (41.4%) grade II and 44 (30.3%) grade I. Regarding etiology, lithiasis was the predominant cause of cholangitis, with 99 patients showing choledocholithiasis on ERCP. Malignant biliary strictures accounted for 12 cases (8.2%), and among these, 50%presented with a previously placed biliary stent. Only 12 patients (8.3%) underwent ERCP within 24 hours of admission - 4 with grade III, 4 with grade II and 4 with grade I. Within 72 hours, 56 patients (38.6%) had undergone ERCP - 21 with grade III, 20 with grade II and 15 with grade I. Notably, 49% of grade III cases were submitted to ERCP more than 72 hours after admission, with a median of 2 days of antibiotics before drainage. There was no statistically significant association between ERCP timing and patient age, cholangitis severity, intensive/intermediate care admission or anticoagulant/antiplatelet use. Among organ dysfunction criteria, only neurological dysfunction showed a statistically significant association with earlier ERCP (p=0.032). Admission on Friday to Sunday strongly predicted delayed intervention (p<0.001), 84% of these patients underwent ERCP more than 72 hours after admission, compared with 45% for weekday admissions. Cholangitis severity was significantly correlated with length of hospital stay (grade I: 7.6 ± 3 days, grade II: 7.7 ± 4 days, grade III: 12.3 ± 4 days; p<0.001). The 30-day mortality rate was 3.4%, with no significant association with ERCP timing or cholangitis severity. The median age of patients who died was 88 years (range 86–97). Only one death was directly attributed to severe acute cholangitis, in which ERCP was performed past the guideline recommended timing. 

In this real-world cohort, ERCP was frequently delayed beyond the recommended window, even in severe acute cholangitis. Weekend admission was a significant contributor to this delay. However, no association was found between ERCP timing and 30-day mortality, likely due to small sample size. These findings highlight the need for optimized access to biliary drainage, particularly during weekends, to better meet guideline recommendations.