Retrospective Cohort Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Oct 16, 2023; 11(29): 6984-6994
Published online Oct 16, 2023. doi: 10.12998/wjcc.v11.i29.6984
Acute cholangitis: Does malignant biliary obstruction vs choledocholithiasis etiology change the clinical presentation and outcomes?
Yung-Kuan Tsou, Yi-Tse Su, Cheng-Hui Lin, Nai-Jen Liu
Yung-Kuan Tsou, Yi-Tse Su, Cheng-Hui Lin, Nai-Jen Liu, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
Author contributions: Tsou YK contributed to the conceptualization of the study and original manuscript writing; Su YT contributed to data collection, planning, interpretation and formal analysis; Lin CH contributed to manuscript review and editing; Liu NJ worked on the conceptualization of the study and revised the final version of the submitted manuscript.
Institutional review board statement: This study was reviewed and approved by the Ethics Committee of the Chang Gung Memorial Hospital (IRB No. 202201601B0).
Informed consent statement: Since this was a retrospective study using routine clinical treatment or diagnostic medical records, the Chang Gung Medical Foundation Institutional Review Board approved the waiver of the participant's consent.
Conflict-of-interest statement: The authors declare no conflict of interest.
Data sharing statement: Deidentified individual participant data are available and will be provided on reasonable request to the corresponding author.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nai-Jen Liu, MD, Assistant Professor, Doctor, Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, No. 5 Fu-Shin Street, Kweishan, Taoyuan 333, Taiwan. milk1372@cloud.cgmh.org.tw
Received: August 13, 2023
Peer-review started: August 13, 2023
First decision: August 24, 2023
Revised: September 2, 2023
Accepted: September 26, 2023
Article in press: September 26, 2023
Published online: October 16, 2023
Processing time: 61 Days and 0.4 Hours
Abstract
BACKGROUND

Whether clinical outcomes of acute cholangitis (AC) vary by etiology is unclear.

AIM

To compare outcomes in AC caused by malignant biliary obstruction (MBO) and common bile duct stones (CBDS).

METHODS

This retrospective study included 516 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) due to AC caused by MBO (MBO group, n = 56) and CBDS (CBDS group, n = 460). Clinical and laboratory parameters were compared between the groups. Propensity score matching (PSM) created 55 matched pairs. Confounders used in the PSM analysis were age, sex, time to ERCP, and technical success of ERCP. The primary outcome comparison was 30-d mortality. The secondary outcome comparisons were intensive care unit (ICU) admission rate, length of hospital stay (LOHS), and 30-d readmission rate.

RESULTS

Compared with the CBDS group, the MBO group had significantly lower body temperature, percentage of abnormal white blood cell counts, and serum levels of aspartate aminotransferase, alanine aminotransferase, and creatinine. Body temperature, percent abnormal white blood cell count, and serum aspartate aminotransferase levels remained significantly lower in the MBO group in the PSM analysis. Platelet count, prothrombin time/international normalized ratio, and serum levels of alkaline phosphatase and total bilirubin were significantly higher in the MBO group. The MBO group had a significantly higher percentage of severe AC (33.9% vs 22.0%, P = 0.045) and received ERCP later (median, 92.5 h vs 47.4 h, P < 0.001). However, the two differences were not found in the PSM analysis. The 30-d mortality (5.4% vs 0.7%, P = 0.019), ICU admission rates (12.5% vs 4.8%, P = 0.028), 30-d readmission rates (23.2% vs 8.0%, P < 0.001), and LOHS (median, 16.5 d vs 7.0 d, P < 0.001) were significantly higher or longer in the MBO group. However, only LOHS remained significant in the PSM analysis. Multivariate analysis revealed that time to ERCP and multiple organ dysfunction were independent factors associated with 30-d mortality.

CONCLUSION

MBO patients underwent ERCP later and thus had a worse prognosis than CBDS patients. Therefore, clinicians should remain vigilant in MBO patients with clinically suspected AC, and perform ERCP for biliary drainage as soon as possible.

Keywords: Malignant biliary obstruction; Common bile duct stones; Endoscopic retrograde cholangiopancreatography; Acute cholangitis; Mortality; Etiology

Core Tip: Our aim was to compare the outcomes of acute cholangitis (AC) with those of two common causes, malignant biliary obstruction (MBO) and common bile duct stones. We found that clinical manifestations such as body temperature, percentage of abnormal white blood cell count, and serum aspartate aminotransferase levels were significantly lower in the MBO group. The MBO group also had a significantly higher proportion of severe AC and a longer time to endoscopic retrograde cholangiopancreatography (ERCP). The 30-d mortality rate was significantly higher in the MBO group. Therefore, early recognition and early acceptance of ERCP are critical for MBO patients with AC.