Background: The data on acute cholangitis in the octogenarian population are very limited. This study aimed to examine the clinical characteristics of acute cholangitis and complications related to endoscopic retrograde cholangiopancreatography (ERCP) in octogenarians. Materials and Methods: This study was conducted prospectively between July 2022 and December 2023 and included 250 patients aged 65 years and older. Patients eligible for the study were divided into two groups: those aged ≥80 years (octogenarian) and those aged 65–79 years (non-octogenarian). These two groups were compared in terms of the clinical characteristics of cholangitis and ERCP-related complications. In addition, factors associated with in-hospital mortality were evaluated. Results: Out of 250 patients, 87 (34.8%) were octogenarians and 163 (65.2%) were non-octogenarians. The median age was 76 (69–82) years. Although the octogenarian group had higher rates of severe illness and intensive care unit admissions (p < 0.001 and p = 0.002, respectively), there were no significant differences in in-hospital mortality (p = 0.359) or ERCP-related complications (p = 0.417). Malignant etiology (odds ratio [OR]: 5.68, 95% confidence interval [CI]: 2.11–15.3), hypoalbuminemia (OR 0.18, 95% CI 0.07–0.45), and qSOFA score ≥ 2 (OR: 6.5, 95% CI: 1.7–24.5) were independent risk factors for in-hospital mortality. Conclusions: Being over 80 years old is not an indicator of poor outcomes, and ERCP can be safely performed on these patients. However, elderly patients with hypoalbuminemia, malignant etiology, or a qSOFA score of ≥2 should be closely monitored, regardless of their age.

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