Introduction
According to guidelines for acute cholangitis management (Tokyo 2018), urgent drainage of the biliary tract is indicated in moderate and severe cases. However, it does not consider factors such as bacteraemia or comorbidities. In addition, the availability of immediate biliary drainage may be limited in some centres.
Aims & Methods
Aims: To evaluate the clinical characteristics of acute cholangitis in our environment and to identify predictive factors of severity.
Methods: A retrospective study of clinical and analytical variables at admission of 331 patients diagnosed with acute cholangitis at Hospital del Mar (2018-2021). Analysis of predictive factors for mortality during admission and at 30 days from discharge. Severty was assessed as association of mortality with clinical, haemodynamic and analytical variables analyzed via logistic regression. Analysis of differences in mortality between early drainage (before 48 hours) and late drainage through Pearson Chi squared test.
Results
The average age was 78 years, 53% were men, 35% had a smoking habit and 17.5% had a Charlson index of high morbidity (>5p). As relevant antecedents they had: diabetes (32.1%), COPD (11.48%), heart failure (16.92%) and ischaemic heart disease (10.3%). The causes of cholangitis were: choledocholithiasis (48.33%) and both benign and malignant strictures (24.92%), 26.75% of cholangitis did not have a clear cause. Choledocholithiasis was diagnosed by endoscopic ultrasound (41.67%), CT scan (23.72%), magnetic ressonance (19.87%) or abdominal ultrasound (14.74%). 197 patients required biliary drainage, median time to drainage of 5 days. The median hospital stay was 9 days and 6.65% of patients needed intensive care unit (ICU) admission.
Mortality was 4.23% during admission and 3.34% at 30 days from discharge. Intra-hospital mortality was related to high morbidity (p<0,002), a malignant aetiology of the cholangitis (p<0,026), alkaline phosphatase (AP) >300UI/L (p<0,005), CRP (C reactive protein) >8mg/dl (p<0,006), low albumin <3,3g/dl (p<0,007) and high leukocytes >12x10^3/uL (p<0,022). Mortality at 30 days was associated with low levels of albumin, high levels of AP and CRP, high morbidity and a malignant origin of the cholangitis. In the multivariate analysis for intrahospital mortality, having high morbidity, AP>300 U/L and CRP>8mg/dl, were predictors of intra-hospital mortality (OR 2,34, IC 95% 1,19-4,16; OR 6,37 IC 95% 1,20-31,01; OR 5,10 IC95% 1,05-24,68; respectively). A malignant origin of a biliary stenosis was significantly associated with higher risk of mortality at 30 days after discharge (OR 12,57 IC 95% 1,58-100,17). There were no differences in mortality of moderate and severe cholangitis between those drained before 48h of admission and those drained after 48h (p=0,571). In those patients who had the risk factors for mortality we identified, no differences in mortality were found between drainage before and after 48h of admission.
Conclusion
Patients with a high Charlson score, initial PA >300 U/L or initial CRP >8 mg/dL have a higher risk of mortality and therefore, should be considered as useful factors to prioritize those patients who need urgent drainage.
