Early identification of the need for biliary drainage in acute calculous cholangitis: a prospective cohort study

Objectives Early identification of patients with acute calculous cholangitis (AC) who will require biliary drainage at emergency department presentation is essential for appropriate triage and timely intervention; however, reliable predictors of drainage requirement remain incompletely defined. Methods In this prospective study conducted between August 2022 and March 2023 at a tertiary referral center, 213 adult patients diagnosed with AC according to the Tokyo Guidelines 2018 were enrolled. Patients were categorized according to whether biliary drainage was performed during hospitalization. Baseline clinical and laboratory variables obtained at presentation were analyzed to identify independent predictors of drainage requirement using multivariate logistic regression adjusted for Tokyo Guidelines 2018 severity. Results Of 213 patients, 145 (68.1%) underwent biliary drainage. History of cholecystectomy [odds ratio (OR): 5.782, 95% confidence interval (CI): 1.266–26.416, P = 0.024], the absence of concomitant pancreatitis (OR: 7.745, 95% CI: 3.341–17.957, P < 0.001), total bilirubin (OR: 1.184, 95% CI: 1.027–1.365, P = 0.020), and procalcitonin (OR: 1.040, 95% CI: 1.005–1.076, P = 0.023) were independently associated with drainage requirement. The combined predictive model demonstrated acceptable discrimination (area under the curve: 0.790, P < 0.001). Optimal cutoffs were 3.6 mg/dl for total bilirubin and 3 μg/l for procalcitonin. During the 3-month follow-up after discharge, recurrent AC occurred in 12 patients (5.6%) and did not differ between groups. Conclusion Readily available parameters at emergency department presentation may facilitate early risk stratification for biliary drainage in AC and may enhance individualized decision-making when integrated into routine clinical assessment. External validation in larger multicenter cohorts is warranted before routine clinical implementation.