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Acute
Cholangitis Clinical
Presentation
Updated: Dec 29, 2017 | Author: Timothy M Scott, DO;
Chief Editor: Barry E Brenner, MD, PhD, FACEP more...

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History
In 1877, Charcot described cholangitis as a triad
of findings of right upper quadrant (RUQ) pain,
fever, and jaundice. The Reynolds pentad adds
mental status changes and sepsis to the triad. A
spectrum of cholangitis exists, ranging from mild
symptoms to fulminant overwhelming sepsis.
With septic shock, the diagnosis can be missed
in up to 25% of patients.

Consider cholangitis in any patient who appears

septic, especially in patients who are elderly,
jaundiced, or who have abdominal pain. A
history of abdominal pain or symptoms of
gallbladder colic may be a clue to the diagnosis.

Symptoms include the following:

Charcot's triad consists of fever, RUQ pain,

and jaundice. It is reported in up to 50-70%
of patients with cholangitis. However,
recent studies believe it is more likely to
be present in 15-20% of patients.

Fever is present in approximately 90% of

cases.

Abdominal pain and jaundice is thought to

occur in 70% and 60% of patients,
respectively.

Patients present with altered mental status

10-20% of the time and hypotension
approximately 30% of the time. These
signs, combined with Charcot's triad,
constitute Reynolds pentad.

Consequently, many patients with

ascending cholangitis do not present with
the classic signs and symptoms. [11]

Most patients complain of RUQ pain;

however, some patients (ie, elderly
persons) are too ill to localize the source of
infection.

Other symptoms include the following:

Jaundice

Fever, chills, and rigors

Abdominal pain

Pruritus

Acholic or hypocholic stools

Malaise

The patient's medical history may be helpful.

For example, a history of the following increases
the risk of cholangitis:

Gallstones, CBD stones

Recent cholecystectomy

Endoscopic manipulation or ERCP,

cholangiogram

History of cholangitis

History of HIV or AIDS: AIDS-related

cholangitis is characterized by
extrahepatic biliary edema, ulceration, and
obstruction. The etiology is uncertain, but
it may be related to cytomegalovirus or
Cryptosporidium infections. The
management of this condition is described
below, although decompression is usually
not necessary.

Physical Examination
In general, patients with cholangitis are quite ill
and frequently present in septic shock without
an apparent source of the infection.

Physical examination may reveal the following:

Fever (90%), although elderly patients may

have no fever

RUQ tenderness (65%)

Mild hepatomegaly

Jaundice (60%)

Mental status changes (10-20%)

Sepsis

Hypotension (30%)

Tachycardia

Peritonitis (uncommon, and should lead to

a search for an alternative diagnosis)

Differential Diagnoses

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Acute Cholangitis

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Physical Examination

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