Upper gastrointestinal hemorrhage is associated with poor outcomes among patients with acute cholangitis: a nationwide analysis.

OBJECTIVE: Acute cholangitis (AC) and upper gastrointestinal hemorrhage (UGIH) are common emergencies encountered by gastroenterologists. We aimed to evaluate the impact of UGIH on in-hospital mortality, morbidity and resource utilization among patients with AC. PATIENTS AND METHODS: Adult admissions with a principal diagnosis of AC were selected from the National Inpatient Sample 2010-2014. The exposure of interest was significant UGIH (requiring red blood cell transfusion). The primary outcome was in-hospital mortality. Secondary outcomes were significant UGIH's incidence, morbidity (shock, prolonged mechanical ventilation and total parenteral nutrition), and resource utilization (length of hospital stay and total hospitalization charges and costs). Confounders were adjusted for using propensity matching and multivariate regression analysis. RESULTS: A total of 50 375 admissions were included in the analysis, 747 of whom developed significant UGIH. After adjusting for confounders, the adjusted odds ratio (aOR) of in-hospital mortality for patients who developed UGIH was 7.1 (95% confidence interval: 2.1-23.9, P<0.01) compared with those who did not. Significant UGIH was associated with substantial increase in morbidity [shock: aOR: 4.1 (2.1-9.3), P<0.01, prolonged mechanical ventilation: aOR: 5.8 (2.2-12.4), P<0.01, total parenteral nutrition: aOR: 4.7 (1.9-10.7), P<0.01], and resource utilization [mean adjusted difference in: length of hospital stay: 7.01 (4.72-9.29), P<0.01 and total hospitalization charges: $81 818 ($58 109-$105 527), P<0.01 and costs: $25 230 ($17 805-$32 653), P<0.01]. Similar results were obtained using multivariate regression analysis. CONCLUSION: Onset of significant UGIH among patients hospitalized with AC has a detrimental effect on in-hospital mortality, morbidity and resource utilization.

Outcomes Associated With Timing of ERCP in Acute Cholangitis Secondary to Choledocholithiasis.

GOALS: To determine the outcomes associated with timing of endoscopic retrograde cholangiopancreatography (ERCP) in patients with acute cholangitis due to choledocholithiasis, from a population-based study. BACKGROUND: Although ERCP is the cornerstone in the management of patients with acute cholangitis due to choledocholithiasis, the effect of timing of ERCP on health care outcomes is not well known. MATERIALS AND METHODS: In this retrospective study, national inpatient sample (NIS) data were used to identify patients with a combined primary or secondary diagnosis of cholangitis and choledocholithiasis from 1998 to 2012. Patients were divided into 4 groups based on timing of ERCP after admission: (1) ERCP performed within 24 hours (urgent ERCP); (2) ERCP performed between 24 and 48 hours (early ERCP); (3) ERCP performed after 48 hours (delayed ERCP); and (4) no ERCP performed. Main outcomes measured were length of stay (LOS), hospitalization charges, and in-hospital mortality. RESULTS: A total of 107,253 patients were identified of which 77,323 patients underwent ERCP at any point in time. Urgent ERCP group had shortest LOS, while delayed ERCP group had significantly longer LOS than all other groups (P<0.001). Delayed ERCP group had also the highest costs (P<0.001). In-hospital mortality was highest in no ERCP group, followed by delayed ERCP group (P<0.001); there was no difference in mortality between urgent ERCP and early ERCP. CONCLUSIONS: This study provides robust, population-based evidence that ERCP should not be delayed for >48 hours in patients with acute cholangitis due to choledocholithiasis.

Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study.

BACKGROUND & AIMS: The management of acute biliary diseases often involves endoscopic retrograde cholangiopancreatography (ERCP), but it is not clear whether this technique reduces mortality. We investigated whether mortality from acute biliary diseases that require ERCP has been reduced over time and explored factors associated with mortality. METHODS: We conducted a cohort study using the Nationwide Inpatient Sample (1998-2008). We identified hospitalizations for choledocholithiasis, cholangitis, and acute pancreatitis that involved ERCP. Multivariate analyses were used to determine the effects of time period, patient factors, hospital characteristics, features of the ERCP procedure, and types of cholecystectomies on mortality, length of stay, and costs. RESULTS: From 1998 to 2008 there were 166,438 admissions for acute biliary conditions that met the inclusion criteria, corresponding to more than 800,000 patients nationwide. During this interval, mortality decreased from 1.1% to 0.6% (adjusted odds ratio [aOR], 0.7; 95% confidence interval [CI], 0.6-0.8), diagnostic ERCPs decreased from 28.8% to 10.0%, hospitals performing fewer than 100 ERCPs per year decreased from 38.4% to 26.9%, open cholecystectomies decreased from 12.4% to 5.8%, and unsuccessful ERCPs decreased from 6.3% to 3.2% (P < .0001 for all trends). Unsuccessful ERCP (aOR, 1.7; 95% CI, 1.4-2.2), open cholecystectomy (aOR, 3.4; 95% CI 2.7-4.3), cholangitis (aOR, 1.9; 95% CI, 1.5-2.3), older age, having Medicare health insurance, and comorbidity were associated with increased mortality. CONCLUSIONS: In-hospital mortality from acute biliary conditions requiring ERCP in the United States has decreased over time. Reductions in the rate of unsuccessful ERCPs and open cholecystectomies are associated with this trend.

Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis.

BACKGROUND & AIMS: Acute ascending cholangitis usually is treated with antibiotics, and biliary drainage is treated by endoscopic retrograde cholangiopancreatography (ERCP). We investigated the effects of the timing of ERCP on outcomes of patients with acute cholangitis factors that predict prolonged hospital stays, increased costs of hospitalization, and composite clinical outcomes (death, persistent organ failure, and admission to the intensive care unit). METHODS: We performed a retrospective analysis of data from 90 patients (mean age, 60 y; 48% female) admitted to Johns Hopkins Hospital from January 1994 to June 2010 who were diagnosed with acute cholangitis and underwent ERCP. A delayed ERCP was defined as one performed more than 72 hours after admission. Electronic and paper medical records were reviewed, and relevant data were abstracted. RESULTS: ERCP was performed successfully in 92% of the patients, at a mean time period of 38 hours after admission (14% of ERCPs were delayed). Factors that were associated independently with prolonged length of hospital stay (top 10%) included unsuccessful ERCP (odds ratio [OR], 52.5; P = .002) and delayed ERCP (OR, 19.8; P = .008). Factors associated with increased hospitalization cost (top 10%) included unsuccessful ERCP (OR, 33.8; P = .004) and delayed ERCP (OR, 11.3; P = .03). Factors associated with composite clinical outcome included age (OR, 1.1; P = .01), total level of bilirubin (OR, 1.36; P = .002), and delayed ERCP (OR, 7.8; P = .04). CONCLUSIONS: Delayed and failed ERCP are associated with prolonged hospital stays and increased costs of hospitalization. Delayed ERCP is associated with composite clinical outcome (death, persistent organ failure, and/or intensive care unit stay). Older age and higher levels of bilirubin also are associated with patients' composite end point.

Long-term biliary endoscopic sphincterotomy restenosis: incidence, endoscopic management, and complications of retreatment.

BACKGROUND: Ampullary restenosis is a late complication of biliary endoscopic sphincterotomy. Long-term data are limited regarding both the rate of restenosis and complications resulting from repeat therapy. AIMS: To determine the incidence of post sphincterotomy restenosis and the effectiveness of endoscopic therapy in the management of this entity. METHODS: A retrospective review of medical charts and the endoscopic retrograde cholangiopancreatography (ERCP) database to identify patients with ERCP and biliary endoscopic sphincterotomy during the period 1998-2002 at the University of Iowa Hospitals was conducted. All subjects were contacted by phone and asked about the recurrence of their pancreatobiliary symptoms after the first ERCP and whether they sought any medical treatment for these symptoms. The primary outcome was restenosis of the sphincterotomy site and the secondary outcome was complications of endoscopic treatment of sphincterotomy restenosis. RESULTS: A total of 202 patients underwent ERCP and biliary endoscopic sphincterotomy on an intact major papilla. Of these, n = 80 patients (54.7 +/- 19 years of age, 76% female) consented and enrolled in the study. Among these, n = 13 (16%) developed ampullary restenosis in 1-62 (median 16) months after the index ERCP. These 13 patients underwent a total of 24 ERCPs (range 1-4 for each patient) for repeat biliary sphincterotomy and biliary stenting, if needed. Repeat biliary endoscopic sphincterotomy was successful in 12/13 (92%) patients. Complications of repeat biliary endoscopic sphincterotomy were seen in three patients: mild pancreatitis (n = 1), severe bleeding (n = 1), and severe duodenal perforation (n = 1). CONCLUSIONS: Long-term restenosis is an important sequella of biliary endoscopic sphincterotomy. Repeat biliary endoscopic sphincterotomy is an effective treatment modality, but complications are not negligible.