Association Of The Timing Of ERCP With Clinical Outcomes In Non-Severe Acute Cholangitis

Background: Acute cholangitis (AC) is a common and frequent biliary tract infectious disease which commonly secondary to obstruction of bile duct.The clinical prognosis varies from the severity grading of AC.Presently,endoscopic retrograde cholangio pancreatography (ERCP) is the first-line management of AC.However,there is a lack of well-designed studies investigating the association between timing of ERCP and clinical outcomes for non?severe AC.Early diagnosis of SAC and intervening effectively and urgently can avoid the occurrence of adverse events result from its deterioration and development.However,risk factors for SAC have been fully characterized in few literatures,and the sensitive parameter for early diagnosis of SAC is not clear.Objective: This study aimed to investigate the clinical outcomes associated with timing of ERCP in non?severe AC,to identify the potential risk factors for SAC caused by common bile duct stones and to evaluate the clinical value of procalcitonin (PCT) in early prediction and diagnosis of SAC.Methods: Patients with AC who treated in the First Affiliated Hospital of Nanchang University between January 2015 and December 2017 were retrospectively reviewed and enrolled in analysis after fulfilling selection criteria.The severity of AC was graded according to the 2018 Tokyo Guidelines (TG18),and classified as mild,moderate and severe.1.According to the time from admission to ERCP,patients were divided into T < 24 h (urgent ERCP)group and T ? 24 h (elective ERCP)group.Clinical data were obtained through telephone or by searching the medical records.Clinical outcomes after ERCP were compared and analyzed between patients from T <24 h and T ? 24 h group.2.Logistic regression model was used for univariate and multivariate analysis to identify independent risk factors of SAC secondary to common bile duct stones.A receiver operating characteristic (ROC) curve and a risk model of the nomogram were generated for qualifying independent risk factors.3.The ability of PCT level on admission to predict moderate/severe (vs.mild) or severe (vs.mild/moderate) AC with the abilities of CRP level,WBC count and N% were compared.Results: A total of 548 patients were hospitalized in the digestive department of our hospital,220 patients were excluded and 328 patients were finally recruited,including the mild group (n=116,male/female=70/96,mean age 60.5 ±14.9 years),moderate group (n=71,male/female=39/32,mean age 67.5 ±15.8 years),severe group(n = 91,male/female = 49/42,mean age 68.0 ±13.1 years).1.Patients in T < 24 h group were associated with a higher hospitalization cost (P <0.05).However,there were no significant difference in the success rate of ERCP,procedure time,the incidence rate of post-ERCP complication,ICU transfer rate,antibiotic duration,hospital stay,organ dysfunction,in-hospital mortality and re-admission rate within 30 days between the two groups (P > 0.05).2.Multivariate logistic regression analyses showed that smoking(odds ratio [OR] 4.487,95% confidence interval [CI] 1.257-16.014,P=0.021),PCT (OR 1.041,95%CI 1.014-1.069,P=0.003),PLT (OR 0.990,95%CI 0.981-0.999,P=0.028) and SOFA score(OR 1.503,95%CI 1.128-2.004,P=0.005)were independent risk factors for the development of SAC.The prediction model incorporating these factors demonstrated an area under the ROC curve of 0.929(95%CI 0.880-0.978,P<0.001).3.The levels of PCT,CRP and N% on admission increased significantly according to the severity of AC.The ROC-AUC for PCT for SAC was 0.823 and was significantly greater than that for CRP(0.742),WBC(0.573)and N%(0.664).The optimal cutoff value for PCT for prediction of SAC was 6.7 ng/mL(sensitivity 0.90,specificity 0.74).The ?AUC between PCT and CRP,WBC as well as N% for moderate/severe AC were not significantly different(P>0.05).Conclusions: 1.The optimal timing of ERCP had no significant influence on the clinical outcomes of non-severe AC patients,including ICU transfer rate,ERCP-related complications,antibiotic duration,hospital stay,organ dysfunction,in-hospital mortality and re-admission rate within 30 days.2.Smoking,SOFA score,PCT and PLT may be independent risk factors for SAC secondary to common bile duct stones.3.PCT is superior to traditional inflammatory markers including CRP,WBC and N% in the early diagnosis of SAC,and plays an important role in the severity grading of AC and for categorizing urgent ERCP cases.