The prognostic value of Neutrophil-Lymphocyte ratio as an early predictor of clinical outcomes in acute Cholangitis

Abstract Background Acute cholangitis is a life-threatening biliary infection associated with substantial morbidity and mortality if not promptly managed. Early identification of high-risk patients is crucial for improved outcomes. The neutrophil–lymphocyte ratio (NLR) is a simple inflammatory marker increasingly recognized as a prognostic tool in infectious diseases. However, data about its utility in predicting morbidity and mortality in Egyptian patients with acute cholangitis remain limited and warrant further investigation. Therefore, this study aimed to evaluate the prognostic value of the neutrophil–lymphocyte ratio in predicting morbidity and mortality in Egyptian patients with acute cholangitis. Methods This cohort study was conducted over six months at Al-Raghy Liver Hospital, Assiut University Hospital, including 100 adult patients diagnosed with acute cholangitis. Clinical and laboratory assessments for all enrolled patients included abdominal ultrasonography, liver function tests, complete blood count for NLR calculation, C-reactive protein, erythrocyte sedimentation rate, and renal function tests. Results The study involved 100 acute cholangitis patients (mean age 51, 60% male), ERCP was the commonest drainage method (60%). The mean NLR was 21.8 ± 11.2. Mortality was 16%; non-survivors had significantly higher NLR (33.4 vs. 19.6, p < 0.001), CRP (173.6 vs. 75.7 mg/L), and more frequent cholangiocarcinoma (87.5%, p < 0.001). ERCP was exclusive to survivors; all non-survivors had PTD ( p < 0.001). Patients with hospital stays ≥ 5 days were older (mean 53.3 vs. 47.2 years), more often male, and had elevated NLR (27.2 vs. 13.9, p < 0.001), WBC $$\:(\times\:{10}^{3}/\mu\:L)$$ , CRP $$\:\left(\text{mg/L}\right)$$ , INR (ratio), and total bilirubin $$\:\left(\text{mg/dL}\right)$$ . An NLR cutoff of 19.5 predicted mortality with 100% sensitivity/NPV, 66.7% specificity, and AUC 0.815; for prolonged stay, sensitivity was 70% and specificity 95%. NLR correlated significantly with age, WBC, INR, CRP, creatinine, and hospital stay, but not with platelets, albumin, or bilirubin. Conclusions This study identified an elevated neutrophil–lymphocyte ratio as a strong predictor of morbidity and mortality in acute cholangitis. Patients with NLR above 19.5 have higher risks of death and prolonged hospital stay. Routine NLR assessment on admission provides a simple, accessible tool for early risk stratification, particularly valuable in low‑resource settings.