Association of ERCP Timing with Clinical Outcomes in Acute Cholangitis Secondary to Choledocholithiasis: A Retrospective Cohort Study

Background/Objectives: The optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute cholangitis remains controversial. This study evaluated the association between ERCP timing and clinical outcomes in patients with acute cholangitis secondary to choledocholithiasis. Methods: This retrospective cohort study included 271 consecutive patients treated between January 2020 and March 2025. Patients were categorized according to ERCP timing as ≤24 h, 24–72 h, and >72 h. Only patients with successful biliary cannulation and drainage during the index ERCP who did not require repeat ERCP were included. Disease severity was assessed using Tokyo 2018 severity grades, qSOFA scores, and Charlson Comorbidity Index (CCI). Hospital stay, intravenous antibiotic duration, complications, and 30-day mortality were analyzed. Corrected post-ERCP hospitalization duration was additionally calculated by excluding the admission-to-ERCP interval. Results: Age, CCI, and Tokyo severity grades were comparable among groups, whereas qSOFA scores differed significantly (p = 0.015). Admission neutrophil-to-lymphocyte ratio was highest in the ≤24 h group (p = 0.014). Overall complication rates were similar among groups (p = 0.136). Thirty-day mortality differed according to ERCP timing and was highest in patients undergoing ERCP within 24 h (16.7% vs. 5.6% vs. 6.6%, p = 0.020). Corrected post-ERCP hospital stay remained significantly longer in the >72 h group (p = 0.045). Multivariable analysis identified increasing age and CCI > 5 as independent predictors of mortality. After multivariable adjustment, ERCP performed between 24 and 72 h was associated with lower mortality than ERCP performed within 24 h, although residual confounding by indication cannot be excluded. Biliary stent placement was more common among older and more comorbid patients but was not associated with differences in mortality or other clinical outcomes. Conclusions: In patients with acute cholangitis secondary to choledocholithiasis, increasing age, greater comorbidity burden, and ERCP timing were independently associated with mortality. However, the higher mortality observed in patients undergoing ERCP within 24 h most likely reflected greater baseline physiological instability rather than a detrimental effect of early biliary drainage. Although delayed ERCP was associated with prolonged corrected post-procedural hospitalization, complication rates were similar across groups. The higher mortality observed in the ≤24 h group may reflect greater physiological instability at presentation rather than the effect of urgent ERCP itself. Similarly, no significant association was observed between biliary stent placement and clinical outcomes.