Acute cholangitis results from bacterial infection superimposed on biliary obstruction [5, 8]. While international guidelines recommend timely biliary drainage according to disease severity, they provide limited guidance on specific timing [7]. Several studies have investigated various thresholds—within 24, 48, or 72 h—with consistent findings that delays beyond 48–72 h are linked to worse outcomes, including increased mortality, persistent organ failure, and longer hospital stays [9–12]. National registry data from 77,323 patients have shown higher in-hospital mortality and longer hospital stays with delayed ERCP, especially after 48 h [13]. Similarly, delayed intervention has been associated with greater healthcare costs, ICU utilization, and 30-day readmission rates [14]. However, the benefits of performing ERCP within 24 h remain less well established.

Some large multicenter studies and meta-analyses suggest a potential mortality benefit in grade II cholangitis with ERCP within 24 h, though not consistently observed in patients with more severe illness [1]. A cohort study of 260 cholangitis patients with septic shock demonstrated reduced mortality when ERCP was performed within 12 h [4]. Other smaller retrospective studies reported trends favoring early intervention but lacked statistical power to confirm mortality benefit [6, 15]. A recent meta-analysis suggested reduced odds of persistent organ failure with ERCP within 24 h, though statistical significance was not achieved [14].

In this study with propensity score-matched cohort, ERCP performed within 24 h of admission was associated with a significant reduction in in-hospital mortality, particularly in patients with moderate to severe cholangitis secondary to choledocholithiasis. The mortality benefit appeared to stem primarily from a reduction in deaths related to septic shock and respiratory failure. Although ERCP within 24 h shortened the duration of hospitalization, it did not significantly influence rates of persistent organ failure, stone clearance, readmission, or ERCP-related complications. Subgroup analysis further confirmed that the survival advantage of ERCP within 24 h was confined to moderate and severe disease, with no differences observed among patients with mild cholangitis.

Our findings align with emerging evidence [2] that ERCP within 24 h confers a survival benefit, especially in patients with moderate to severe disease. In our cohort, the median time to ERCP in the urgent group was 19.5 h from admission, with an interquartile range of 5–23 h. This indicated that while some patients underwent very early intervention within the first several hours, the majority received ERCP later within the 24-h window. These findings underscore the importance of achieving biliary decompression within the first hospital day. The incidence of persistent organ failure in our cohort was lower than previous studies of 15–22% [9, 10] which may have limited power to detect differences. The mortality benefit despite similar organ failure rates may reflect adequate systemic resuscitation and earlier infection control with efficient biliary decompression. The consistent reduction in mortality, along with a shorter hospital stay in the ERCP within 24 h group (median 5 vs 8 days), suggests meaningful clinical and resource-related advantages.

Approximately 75% of patients in this study achieved complete stone clearance despite the urgency of intervention, which aligns with international quality benchmarks [16]. Major ERCP-related complications, including post-ERCP pancreatitis, bleeding, and perforation, were infrequent, reflecting a high standard of procedural safety even in the urgent setting [16, 17].

This study has a few strengths. It focuses exclusively on patients with choledocholithiasis-induced cholangitis, eliminating confounding from malignant or other non-stone etiologies. Propensity score matching was used to balance key clinical variables and reduce confounding, thereby improving the validity of outcome comparisons. However, the retrospective design introduces potential bias from unmeasured confounding, as patients with higher disease burden may have been prioritized for urgent ERCP, potentially biasing results against the early group. The fact that the early group nonetheless demonstrated significantly better survival suggests that early intervention may confer a genuine benefit; however, this possibility of residual confounding should be acknowledged. Another potential confounder relates to antibiotic therapy. Regimens were similar between urgent and non-urgent groups. Although broader agents such as carbapenems were more frequently used in severe cases, distribution within each severity group was balanced, suggesting that antibiotic selection did not account for the observed mortality difference, though synergy with early source control remains possible. Additionally, the relatively small number of mortality events overall, and within certain subgroups—especially mild disease—limits the statistical power for subgroup mortality analyses. As such, conclusions regarding subgroup-specific survival benefit should be interpreted with caution and considered hypothesis-generating rather than definitive. Finally, the focus on choledocholithiasis limits generalizability to patients with other causes of biliary obstruction, such as malignancy, where the disease course and response to intervention differ substantially [18].

In conclusions, this study highlights the clinical benefit of performing ERCP within 24 h in patients with moderate to severe acute cholangitis due to choledocholithiasis. Thus, the ERCP service for this patient population should focus on severity-based triage protocols and reliable access to endoscopy with biliary drainage within the first day of presentation, particularly in resource-limited settings. Further prospective studies are warranted to validate these findings and to refine the optimal timing of ERCP across different clinical contexts and etiologies.