title: Optimal Timing of Endoscopic Retrograde Cholangiopancreatography in Acute Cholangitis.
abstract: OBJECTIVE
  Acute cholangitis mandates resuscitation, antibiotic therapy, and biliary decompression. Our aim was to define the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis.
  
  
  METHODS
  Clinical data on all cases of cholangitis managed by ERCP were prospectively collected from September 2010 to July 2013. The clinical impact of the time to ERCP, defined as the time from presentation in the emergency department to the commencement of the ERCP, was determined. The primary outcome was length of hospitalization. Secondary outcomes included vasopressor use, endotracheal intubation, intensive care unit admission, and death.
  
  
  RESULTS
  ERCP was successful in 182 (92%) of 199 patients with cholangitis. Length of hospitalization was significantly longer for patients undergoing ERCP at ≥48 versus <48 hours (median 9.1 vs. 6.5 d, P=0.004) even though patients having ERCP at ≥48 hours were less sick as indicated by less frequent intensive care unit admission [odds ratio,0.3; 95% confidence interval (CI), 0.2-0.6]. Multivariate analysis revealed that hospitalization increased by 1.44 days for every day ERCP was delayed (P<0.001). Comparison of ERCP≥72 versus <72 hours revealed odds ratios of 2.6 (95% CI, 1.0-7.0) for vasopressor requirement and 3.6 (95% CI, 0.8-15.9) for mortality. Time to ERCP did not impact technical success or procedural adverse events.
  
  
  CONCLUSIONS
  ERCP should be performed within 2 days of presentation as a delay of 48 or more hours is associated with disproportionate increase in hospital stay. Delay>72 hours is associated with additional adverse outcomes including hypotension requiring vasopressor support.
authors.affiliation: *Department of Medicine, Division of Gastroenterology, UCLA-Olive View Medical Center, Sylmar †David Geffen School of Medicine at UCLA Departments of ∥Medicine, Division of Gastrointestinal and Liver Diseases ¶Preventive Medicine, Keck Medical Center, University of Southern California, Los Angeles, CA ‡Yale School of Medicine, New Haven §VA Connecticut Healthcare System, West Haven, CT.
authors.forename: Linda A
authors.initials: LA
authors.lastname: Hou
authors.forename: Loren
authors.initials: L
authors.lastname: Laine
authors.forename: Nima
authors.initials: N
authors.lastname: Motamedi
authors.forename: Ara
authors.initials: A
authors.lastname: Sahakian
authors.forename: Christianne
authors.initials: C
authors.lastname: Lane
authors.forename: James
authors.initials: J
authors.lastname: Buxbaum
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods*; D002761:Cholangitis / Q000601:surgery*; D005260:Female; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult