Acute cholangitis is a serious complication in patients who have gallstones. Previously, the standard management was to perform an open common bile duct exploration (CBDE). This procedure was associated with high rates of morbidity and mortality. Over the past 10 years, significant developments have been made in the management of patients with gallstones, primarily in the use of laparoscopic cholecystectomy (LC), endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES). The use of these techniques has substantially reduced the morbidity and mortality associated with this condition. Management of common bile duct stones using ERCP with ES and LC is a matter of debate. Poon and associates performed a retrospective analysis of 184 patients with gallstone cholangitis who were consecutively treated over a four–year period.

An equal distribution of men and women was represented in the study. The mean age of the subjects was 70.5 years, with a range from 25 to 96 years. Comorbid illnesses were common, including hypertension, ischemic heart disease, chronic obstructive pulmonary disease, diabetes mellitus and chronic renal insufficiency. The diagnosis of acute cholangitis was based on a history of upper abdominal pain, fever, chills and jaundice. All patients were managed by a single hepatobiliary surgical team and according to a standard protocol. This protocol included the use of broad-spectrum intravenous antibiotics immediately after the diagnosis was made. ERCP with ES was performed immediately or on the day after admission. In patients who had successful endoscopic clearance of CBD stones, an interval LC was performed in six to 12 weeks. In patients in whom ERCP or ES failed, further management was determined by the severity of the cholangitis. Patients with severe cholangitis were managed by emergency open CBDE; patients with mild cholangitis who responded to antibiotic therapy were managed by early elective open CBDE.

ERCP was successful in 175 patients (95 percent). Bile duct stones were found in 147 patients (84 percent). Endoscopic stone clearance was achieved in 132 patients (90 percent). Morbidity after ERCP or ES was 4 percent. The authors conclude that ES for biliary drainage and stone removal, followed by interval LC, is safe and effective.

editor’s note: The information provided by this analysis suggests that ERCP with ES for biliary drainage and stone removal is a safe and effective approach in the management of patients with cholangitis. A limitation of the study is the provision of services by a single hepatobiliary surgical team, which may have influenced the low rates of morbidity and mortality. It will be important to assess outcomes for these procedures from other institutions and providers.—j.n.