title: Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis.
abstract: BACKGROUND
  Predictors of organ failure and the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in patients with acute cholangitis are unclear.
  
  
  OBJECTIVE
  To identify factors associated with persistent organ failure and assess the impact of early ERCP on outcomes in hospitalised patients with cholangitis.
  
  
  METHODS
  Consecutive hospitalised patients who received ERCP at two centres for cholangitis from 4/2005-3/2013 were retrospectively reviewed. Delayed ERCP was defined as ERCP ≥ 48 h after hospitalisation. Primary outcome was persistent organ failure at >48 h after hospitalisation (≥ 1.5 times rise in creatinine levels from baseline values to ≥ 1.5 mg/dL or need for dialysis, mechanical ventilation and/or hypotension requiring vasopressor).
  
  
  RESULTS
  203 patients (mean age 59 ± 19 years) had ERCP for cholangitis: 115 with choledocholithiasis, 48 with other benign obstructions and 40 with malignant strictures. Forty-five (22%) patients had persistent organ failure at >48 h and 11 (5%) died. On multivariate analysis, Charlson Comorbidity Index >2 (OR = 4.6, 95% CI = 1.5-13.8), systemic inflammatory response syndrome (SIRS; OR = 3.2, 95% CI = 1.1-9.8), hypoalbuminemia (OR = 3.3, 95% CI = 1.4-7.9), bacteremia (OR = 2.8, 95% CI 1.3-6.2) and delayed ERCP(OR = 3.1, 95% CI: 1.4-7.0) were associated with persistent organ failure. Every 1-day delay in ERCP was associated with a 17% (95% CI = 5-29%) relative risk increase in persistent organ failure after adjusting for significant factors.
  
  
  CONCLUSIONS
  Delay in ERCP beyond 48 h was associated with persistent organ failure in hospitalised patients with acute cholangitis. Other factors included increased comorbidities, SIRS, hypoalbuminemia and bacteremia. Early ERCP performed within 48 h after presentation in patients with cholangitis may improve outcomes.
authors.affiliation: Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA.
authors.forename: F
authors.initials: F
authors.lastname: Lee
authors.affiliation: Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA.
authors.forename: E
authors.initials: E
authors.lastname: Ohanian
authors.affiliation: Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA.
authors.forename: J
authors.initials: J
authors.lastname: Rheem
authors.affiliation: Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT, USA.|VA Connecticut Healthcare System, West Haven, CT, USA.
authors.forename: L
authors.initials: L
authors.lastname: Laine
authors.affiliation: Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA.
authors.forename: K
authors.initials: K
authors.lastname: Che
authors.affiliation: Division of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA, USA.|Department of Gastroenterology, Sir Run Run Shaw Hospital, Zhejiang University, Hangzhou, China.
authors.forename: J J
authors.initials: JJ
authors.lastname: Kim
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000706:statistics & numerical data*; D002761:Cholangitis / Q000175:diagnosis*; D015897:Comorbidity; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000453:epidemiology*; D015999:Multivariate Analysis; D012189:Retrospective Studies; D018746:Systemic Inflammatory Response Syndrome / Q000453:epidemiology