S244 Beyond the Triad: Diagnostic Delays and the Role of Biomarkers in Atypical Acute Cholangitis: A Systematic Review

Introduction: Acute cholangitis is a life-threatening biliary tract infection that demands timely recognition and intervention. Historically diagnosed by Charcot’s triad (fever, RUQ pain, jaundice), recent studies reveal its limited sensitivity, especially in elderly, immunocompromised, or septic patients. Atypical presentations often lead to delayed diagnosis and worse clinical outcomes. This systematic review aims to evaluate diagnostic limitations of current frameworks and explore the utility of emerging biomarkers—procalcitonin (PCT), serum lactate, and hepatic artery velocity (HAV)—in detecting atypical cholangitis. Methods: We conducted a systematic review using PubMed, Scopus, EMBASE, CENTRAL, and Web of Science through May 2025. Studies involving adults (≥18 years) with confirmed cholangitis, reporting clinical features, biomarkers, or outcomes, were included. Data extraction followed PRISMA guidelines. Diagnostic accuracy and outcomes (ICU admission, mortality, time to endoscopic retrograde cholangiopancreatography, length of stay) were analyzed. Subgroup analyses were conducted for PCT, lactate, and HAV. Results: Nineteen studies involving >3,200 patients from 11 countries were included. Charcot’s triad had low sensitivity (25%–45%), while Tokyo Guidelines (TG13/TG18) showed improved sensitivity (78%–90%) when paired with imaging/lab parameters. Procalcitonin was elevated in cholangitis compared to other infections (AUC 0.87–0.91), outperforming CRP and WBC. Lactate >2.0 mmol/L predicted ICU need and higher severity (P < 0.01). HAV ≤25 cm/s correlated with biliary obstruction in Doppler studies. Biomarker-guided strategies led to earlier endoscopic retrograde cholangiopancreatography (by 6–18 hours), shorter hospital stay (↓2.1 days, P < 0.05), and reduced mortality (RR 0.78, 95% CI 0.65–0.94). Conclusion: This review highlights that atypical cholangitis is both common and underrecognized. Over-reliance on Charcot’s triad contributes to diagnostic delays. Biomarkers like PCT, lactate, and HAV can significantly enhance early identification and risk stratification. These findings support revising future guidelines to include biomarker-based criteria for timely diagnosis and improved clinical outcomes.