Sphincterotomy during endoscopic biliary drainage in cholangitis with sepsis-induced coagulopathy increases bleeding without clinical benefits

Yasuhisa Hiroshima; Ryota Sagami; Naosuke Kuraoka; Tatsuya Noguchi; Yasusato Matsuda; Takero Terayama; Yoshifumi Azuma; Takao Sato; Hidefumi Nishikori; Hideho Honda; Yasuhiko Goto; Haruna Noguchi; Satoshi Fukuchi; Kaoru Omori; Mitsuteru Motomura; Tadayoshi Okimoto; Kazuhisa Okamoto; Hideki Mori; Tatsuya Sato; Kosuke Takahashi; Eisuke Ozawa; Eriko Ikeda; Atsushi Kanno; Shunsuke Komoto; Takehiko Koga; Yusuke Ishida; Kiyoyuki Kobayashi; Makoto Hinokuchi; Ryo Ihara; Takahiro Ueda; Nao Fujimori; Osamu Matsunari; Chishio Noguchi; Kazuhiro Mizukami; Kazunari Murakami

doi:10.1016/j.dld.2026.01.218

Sphincterotomy during endoscopic biliary drainage in cholangitis with sepsis-induced coagulopathy increases bleeding without clinical benefits

Dig Liver Dis. 2026 Feb 7:S1590-8658(26)00252-5. doi: 10.1016/j.dld.2026.01.218. Online ahead of print.

Authors

Yasuhisa Hiroshima¹, Ryota Sagami², Naosuke Kuraoka³, Tatsuya Noguchi⁴, Yasusato Matsuda⁴, Takero Terayama⁵, Yoshifumi Azuma¹, Takao Sato⁶, Hidefumi Nishikori⁶, Hideho Honda⁷, Yasuhiko Goto⁷, Haruna Noguchi⁸, Satoshi Fukuchi⁸, Kaoru Omori⁹, Mitsuteru Motomura¹⁰, Tadayoshi Okimoto¹¹, Kazuhisa Okamoto¹², Hideki Mori¹³, Tatsuya Sato¹⁴, Kosuke Takahashi¹⁵, Eisuke Ozawa¹⁶, Eriko Ikeda¹⁶, Atsushi Kanno¹⁶, Shunsuke Komoto¹⁷, Takehiko Koga¹⁸, Yusuke Ishida¹⁸, Kiyoyuki Kobayashi¹⁹, Makoto Hinokuchi²⁰, Ryo Ihara²¹, Takahiro Ueda²², Nao Fujimori²², Osamu Matsunari²³, Chishio Noguchi²⁴, Kazuhiro Mizukami²⁵, Kazunari Murakami¹

Affiliations

¹ Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan.
² Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan; Department of Advanced Gastrointestinal Cancer Medicine, Faculty of Medicine, Oita University, Oita, Japan.
³ Department of Gastroenterology, Saiseikai Kawaguchi General Hospital, Saitama, Japan.
⁴ Department of Gastroenterology, Kokura Memorial Hospital, Fukuoka, Japan.
⁵ Department of Emergency, Self-Defence Forces Central Hospital, Tokyo, Japan.
⁶ Department of Gastroenterology, Oita San-ai Medical Center, Oita, Japan.
⁷ Department of Gastroenterology, Shinbeppu Hospital, Oita, Japan.
⁸ Department of Gastroenterology, Oita City Medical Association Almeida Memorial Hospital, Oita, Japan.
⁹ Department of Gastroenterology, Nakatsu Municipal Hospital, Oita, Japan.
¹⁰ Department of Gastroenterology, Oita Red Cross Hospital, Oita, Japan.
¹¹ Department of Gastrointestinal Medicine, Oita Prefectural Hospital, Oita, Japan.
¹² Department of Gastroenterology, Oita Medical Center, Oita, Japan.
¹³ Department of Gastroenterology, Nakagami Hospital, Okinawa, Japan.
¹⁴ Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
¹⁵ Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
¹⁶ Department of Gastroenterology, Faculty of Medicine, Jichi Medical University, Tochigi, Japan.
¹⁷ Department of Gastroenterology, Faculty of Medicine, National Defense Medical University, Saitama, Japan.
¹⁸ Department of Gastroenterology and Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan.
¹⁹ Division of Innovative Medicine for Hepatobiliary and Pancreatology, Faculty of Medicine, Kagawa University, Kagawa, Japan.
²⁰ Department of Gastroenterology, Faculty of Medicine, Kagoshima University, Kagoshima, Japan.
²¹ Department of Gastroenterology, Kyusyu Central Hospital, Fukuoka, Japan.
²² Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
²³ Department of Gastroenterology, Nakamura Hospital, Oita, Japan.
²⁴ Department of Gastroenterology, Nankai Medical Center, Oita, Japan.
²⁵ Department of Gastroenterology, Faculty of Medicine, Oita University, Oita, Japan. Electronic address: mizkaz0809@oita-u.ac.jp.

PMID: 41656119
DOI: 10.1016/j.dld.2026.01.218

Abstract

Background: Acute cholangitis (AC) is life-threatening, requiring urgent biliary drainage. Endoscopic biliary drainage (EBD), often combined with endoscopic sphincterotomy (EST), may prevent post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). However, sepsis-induced coagulopathy (SIC) increases bleeding risk, raising concerns about EST safety.

Aims: To evaluate the risk of adverse events (AEs) and clinical outcomes associated with EBD with or without EST in patients with AC and SIC.

Methods: In this retrospective multicentre cohort study, data from enrolled patients were analysed using propensity score matching, and outcomes were compared between EST and non-EST groups. The primary endpoint was the AE rate difference between EBD with and without EST. Secondary endpoints included differences in clinical outcomes.

Results: Among 238 patients, 72 underwent EST and 166 did not. The AE incidence, particularly bleeding-related (11.1% vs. 0.6%, P<.001), was higher in the EST group (16.7% vs. 1.8%, P<.001) while PEP incidence (4.2% vs. 1.2%, P=.143) did not differ. Propensity score-matched analysis confirmed these findings. Clinical success or 28-day survival rates did not differ significantly.

Conclusion: EST significantly increases bleeding risk in patients with AC and SIC without reducing PEP incidence or improving clinical outcomes. EBD without EST can minimise bleeding risk while maintaining adequate biliary drainage.

Keywords: Acute cholangitis; Coagulopathy; Endoscopic biliary drainage; Endoscopic sphincterotomy.