SEVERE ACUTE CHOLANGITIS: TIMING OF BILIARY DRAINAGE AND HOSPITAL MORTALITY

Abstract

Severe acute cholangitis requires antimicrobial therapy, organ support, and biliary decompression, yet the optimal procedural window remains uncertain. This article critically examined the association between time to drainage and hospital mortality, focusing on the 48-, 24-, and 12-hour thresholds and on phenotypes with shock or progressive organ dysfunction. A critical narrative review was conducted, with searches performed until August 2026, in PubMed/MEDLINE, the Cochrane Library, SciELO, and LILACS/VHL, complemented by guidelines and official documents. Meta-analyses and large administrative datasets generally favor drainage within 24 to 48 hours, whereas the largest international clinical cohort found no mortality benefit in the aggregated grade III population. Evidence supporting drainage within 12 hours is inconsistent and appears more clinically plausible in septic shock, escalating vasopressor requirements, persistent hyperlactatemia, and neurologic dysfunction, rather than as a universal rule for all grade III cases. Thus, 48 hours should be regarded as an avoidable upper limit, 24 hours as an operational target for most severe cases, and 12 hours or less as a physiology-guided conditional priority. Drainage should be integrated into resuscitation, using the minimum effective source-control procedure when instability makes definitive therapy unsafe.