Purpose 1. To validate the Tokyo 2018 guidelines for management of acute cholangitis 2. To compare outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) treated cholangitis between patients from metropolitan and rural backgrounds. Methodology This study retrospectively reviewed patient with cholangitis treated with ERCP at St. Vincent’s Hospital Melbourne or Box Hill Hospitals from January 2016 to December 2020. There were 566 patients included in this study. Data from medical records were analysed to compare outcomes between metropolitan and rural backgrounds. Results Patients >18 years who underwent ERCP for cholangitis from any cause were included. The 30-day mortality was 6.1%, 3% and 4.2% respectively. The 90-day mortality was 2.9%, 6% and 0.8% respectively. The metropolitan patients had the longest median time to ERCP and highest 30-day mortality. The 30-day mortality for patients who underwent ERCP within 24 hours was 3.5% for Tokyo Grade I, 2.6% for Grade II and 10.6% for Grade III. This was compared with patients who underwent ERCP after 24 hours, which showed 30-day mortality was 0% for Grade I, 3.8% for Grade II and 10.8% for Grade III. Conclusion Patients from rural backgrounds often have less access to ERCP and require transfer to a metropolitan centre. This study demonstrates no major difference in outcomes between patients from metropolitan backgrounds and those from rural backgrounds undergoing ERCP at a tertiary centre. The timing of ERCP did not appear to affect outcomes, however the Tokyo Grade did impact on outcomes. This emphasises the importance of these guidelines.