Objective To explore the therapeutic effect and safety of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute severe cholangitis (ASC) in patients older than eighty. Methods The clinical data of 106 patients aged 80 years and over with ASC who underwent ERCP were reviewed. Results Among 106 cases, there were 95 patients with common bile duct (CBD) stones, and 11 patients with biliary tract neoplasms. The 11 cases with biliary tract neoplasms underwent endoscopic nasobiliary drainage (ENBD) to correct critical situation. After stabilization, surgical treatment or stent placement was performed. The 61 of 95 cases with CBD stones underwent ENBD in critical phase and endoscopic sphincterotomy (EST) plus stone removal for subsequent treatment after stabilization. The 34 of 95 cases with CBD stones underwent EST to remove stones. Procedure-related complications were found in 5 patients. At 24 and 72 hours postoperation, the values of white blood cell count, serum total bilirubin, body temperature, and occurrence rate of patients with shock and mental symptoms were decreased in the other 101 patients.Conclusions For patients aged 80 years and over with ASC, ERCP is a safe and effective procedure.