Acute suppurative cholangitis is a life-threatening condition and prompt biliary decompression (BD) is essential for survival. The evolution of thirty-one patients (21 women and 10 men, mean age 64 years) with acute suppurative cholangitis attended from February 1989 to February 1994 treated by endoscopic cannulation and sphincterotomy for biliary drainage were retrospectively reviewed. The mean hospital stay was 18 +/- 12 days and during hospitalization there were 5 deaths, none related to biliary drainage. Sixteen patients had previous cholecystectomy, 12 patients had previous cholangitis in the last year, 23 patients had choledocholithiasis and an additional three patients pancreatobiliary neoplasias and common duct stones. Only 67.7% showed the classic Charcot's triad (fever, abdominal pain and jaundice). Total bilirubin, aspartate aminotransferase, alanine aminotransferase and total leukocytes decreased significantly (p < 0.05) after BD. Retroperitoneal perforation was the only complication is a safe and effective procedure for emergency biliary decompression in the treatment of acute suppurative cholangitis.