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Original Investigation
Pacific Coast Surgical Association
November 2016

Association of Admission Laboratory Values and the Timing of Endoscopic Retrograde Cholangiopancreatography With Clinical Outcomes in Acute Cholangitis

Author Affiliations
  • 1Department of Surgery, Harbor–University of California-Los Angeles Medical Center, Torrance
  • 2David Geffen School of Medicine, University of California–Los Angeles, Los Angeles
  • 3University of California–Los Angeles, College of Letters and Sciences, Los Angeles
  • 4Meharry Medical College, Nashville, Tennessee
  • 5Los Angeles BioMedical Research Institute, Torrance, California
  • 6Department of Emergency Medicine, Harbor–University of California-Los Angeles Medical Center, Torrance
  • 7Department of Surgery, Olive View–University of California-Los Angeles Medical Center, Sylmar
JAMA Surg. 2016;151(11):1039-1045. doi:10.1001/jamasurg.2016.2329
Key Points

Question  Can admission variables for patients with acute cholangitis improve the current Tokyo Guidelines’ risk stratification?

Findings  In this multicenter cohort of 314 patients, we confirmed our previous findings that patients with cholangitis with an admission white blood cell count greater than 20 000 cells/µL and a total bilirubin level of more than 10 mg/dL were significantly more likely to have an adverse outcome. The timing of endoscopic intervention was not associated with clinical outcomes in this cohort and appeared to be of secondary importance to adequate resuscitation and initiation of antibiotics.

Meaning  Inclusion of prognostic admission variables may improve the current Tokyo Guidelines with respect to severity assessment and subsequent treatment recommendations.

Abstract

Importance  Acute cholangitis (AC), particularly severe AC, has historically required urgent endoscopic decompression, although the timing of decompression is controversial. We previously identified 2 admission risk factors for adverse outcomes in AC: total bilirubin level greater than 10 mg/dL and white blood cell count greater than 20 000 cells/µL.

Objectives  To validate previously identified prognostic factors in AC, evaluate the effect of timing of endoscopic retrograde cholangiopancreatography on clinical outcomes, and compare recent experience with AC vs an historical cohort.

Design, Setting, and Participants  A retrospective analysis (2008-2015) of patients with AC (validation cohort, n = 196) was conducted at 2 academic medical centers to validate predictors of adverse outcome. Timing of endoscopic retrograde cholangiopancreatography and outcome were stratified by severity using the Tokyo Guidelines for acute cholangitis diagnosis. Outcomes for the validation cohort were compared with the derivation cohort (1995-2005; n = 114). Data analysis was conducted from July 1, 2015, to September 9, 2015.

Main Outcomes and Measures  Death and a composite outcome of death or organ failure.

Results  The median age of patients in the derivation cohort was 54 years (interquartile range, 40-65 years) and in the validation cohort was 59 years (45-67 years). Multivariate logistic regression analysis of the validation cohort confirmed white blood cell count of more than 20 000 cells/µL (odds ratio, 3.4; 95% CI, 1.2-9.5; P = .02) and total bilirubin level of more than 10 mg/dL (odds ratio, 5.4; 95% CI, 1.8-16.4; P = .003) as independent risk factors for poor outcomes. In the validation cohort, timing of endoscopic retrograde cholangiopancreatography was not significantly different between those with and without an adverse outcome, even when stratified by AC severity (moderate: median, 0.6 hours [interquartile range (IQR), 0.5-0.9] vs 1.7 hours [IQR, 0.7-18.0] and severe: median, 10.6 hours [IQR, 1.2-35.1] vs 25.5 hours [IQR, 15.5-58.5] for those with and without adverse events, respectively). Patients in the validation cohort had a shorter hospital length of stay (median, 7 days [IQR, 4-10 days] vs 9 days [IQR, 5-16 days]) and lower rate of intensive care unit admission (26% vs 82%), despite a higher rate of severe cholangitis (n = 131 [67%] vs n = 29 [25%]). There were no significant differences in the composite outcome between the validation and derivation cohorts (22 [18.6%] vs 44 [22.4%]; P = .47). Adjusted analysis demonstrated decreased mortality in the validation cohort (odds ratio, 0.3; 95% CI, 0.1-0.7; P = .01).

Conclusions and Relevance  White blood cell count greater than 20 000 cells/µL and total bilirubin level greater than 10 mg/dL are independent prognostic factors for adverse outcomes in AC. Consideration should be given to include these criteria in the Tokyo Guidelines severity assessment. Timing of endoscopic retrograde cholangiopancreatography does not appear to affect clinical outcomes in these patients. Management of AC has improved with time, with an overall shorter hospital length of stay, lower rate of intensive care unit admission, and a decreased adjusted mortality, demonstrating improvements in care efficiency and delivery.

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