Bile aspiration during ERCP in acute cholangitis

Background: Acute cholangitis is a biliary infection treated with antibiotics and biliary decompression, mainly via ERCP. Bile aspiration can identify pathogens but is not always recommended due to limited data. This study evaluated its clinical benefit. Materials and Methods: We retrospectively included patients undergoing ERCP with bile aspiration for acute cholangitis (Jan 2023–Jul 2024). Data on clinical, biological, and bacteriological parameters were collected. The primary outcome was antibiotic adjustment based on bile cultures; secondary outcomes included hospital stay, 30-day recurrence, and mortality. Results: Fifty-seven patients were included (mean age 61.6 ± 13.1 years; 56.1% female). ERCP indications were neoplasia (43.9%) and lithiasis (38.6%). Bile cultures were positive in 68.4%, mainly Escherichia coli and Pseudomonas spp. Antibiotic therapy was adjusted in 48.7% of patients; 26.3% were resistant to empirical therapy, while in 17.5% of sensitive cases therapy was changed to narrower-spectrum or switched to oral antibiotics. Prior biliary sphincterotomy was the only significant predictor of resistance (OR 11.7, p = 0.047). Mean hospital stay was 10 days; 30-day recurrence and mortality rates were 5% and 3.5%, respectively. Conclusion: Bile aspiration during ERCP detected pathogens in two-thirds of cases and guided antibiotic adjustment in nearly half, improving management and allowing narrower-spectrum or oral therapy. Routine bile cultures are recommended, especially for patients undergoing repeated ERCP.