Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases

Abstract

Background and Aims: Endoscopic biliary drainage is an established mode of biliary decompression in patients with acute cholangitis as a result of biliary obstruction secondary to stones and benign strictures. However, there are no reports on endoscopic management of severe acute cholangitis caused by malignant conditions. We prospectively compared the efficacy of the endoscopic drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. Methods: Forty-three patients with severe acute cholangitis requiring urgent biliary drainage were included. Sixteen patients (mean age 58.2 ± 9.3 years; seven men, nine women) had biliary obstruction as a result of malignant diseases and 27 had benign biliary diseases (mean age 41.6 ± 14.3 years; nine men, 18 women). Indications for urgent drainage included any one of the following: temperature >38°C (n = 21), septic shock with systolic blood pressure <100 mmHg (n = 9), localized peritonism (n = 21), impaired consciousness (n = 6) and failure to improve within 72 h of conservative management (n = 13). After successful bile duct cannulation, patients received either a nasobiliary catheter (n = 38) or an in-dwelling stent (n = 5) with or without sphincterotomy for biliary drainage. Outcome measures included complications and clinical response. Results: Endoscopic drainage was established successfully in all the patients in both the groups. Clinical improvement after biliary drainage occurred in 94% patients (15/16) in the malignant group compared with 96% patients (26/27) in the benign group (P = not significant [NS]). Fever subsided at a median of 2.2 days in the malignant group and at 1 day in the benign group (P = NS). Normalization of leukocyte count was seen at a median of 6 days (range 1-17) and 2 days (range 1-5) days in the malignant group and the the benign group, respectively (P = NS). There were no endoscopic retrograde cholangiopancreatography-related complications. The mortality rate as a result of cholangitis was 4.6%, that is two of 43 patients (6.2% of the malignant group vs 3.7% of the benign group; P = NS). Conclusions: Endoscopic biliary drainage is equally effective in patients with severe acute cholangitis caused by either malignant or benign biliary diseases.