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Background  Endoscopic biliary stenting by endoscopic retrograde cholangiopancreatography (ERCP) is the most common form of palliation for malignant hilar obstruction. However, ERCP in such cases is associated with a risk of cholangitis. The incidence of post-ERCP cholangitis is particularly high in Bismuth type IV hilar obstruction, and this risk is further increased when the contrast injected for cholangiography is not drained. The present study aims to compare the incidence of cholangitis associated with the use of a contrast agent, air and CO 2  for cholangiography in type IV hilar biliary lesions.    Methods  The clinical data of consecutive 70 patients with type IV hilar obstruction, who underwent ERCP from October 2013 to November 2017, were retrospectively analyzed. These patients were divided into three groups based on the agent used for cholangiography: group A, contrast ( n  = 22); group B, air ( n  = 18); group C, CO 2  ( n  = 30). These three methods of cholangiography were chronologically separated. Prior to the ERCP, MRCP was obtained from all patients to guide the endoscopic intervention.    Results  At baseline, there was no significant difference in terms of the patient’s age, gender, symptoms and liver function tests among the three groups ( P >  0.05). The complication rates were significantly higher in group A than in groups B and C (63.6% vs. 26.7 and 27.8%,  P <  0.05). The incidence of post-ERCP cholangitis was significantly higher in group A ( P <  0.05), while the incidence of post-ERCP pancreatitis and bleeding were similar in the three groups. After the ERCP, the mean hospital stay was shorter in groups B and C, when compared to group A ( P <  0.05). However, there was no significant difference in the 30-day mortality rate among the three groups ( P >  0.05). Furthermore, there was no significant difference between groups B and C in terms of primary end points.    Conclusion  CO 2  or air cholangiography during ERCP for type IV hilar obstruction is associated with reduced risk of post-ERCP cholangitis, when compared to conventional contrast agents.

CO2 or air cholangiography reduces the risk of post-ERCP cholangitis in patients with Bismuth type IV hilar biliary obstruction