From the Guidelines
Charcot's Pentad is a clinical presentation of ascending cholangitis characterized by five key signs: right upper quadrant abdominal pain, jaundice, fever with chills, hypotension, and altered mental status. The characteristics of Charcot's Pentad are crucial in diagnosing acute cholangitis, a serious bacterial infection of the bile ducts 1. The five components of Charcot's Pentad are:
- Right upper quadrant abdominal pain
- Jaundice (yellowing of skin and eyes)
- Fever with chills
- Hypotension (low blood pressure)
- Altered mental status It's essential to note that while Charcot's Pentad is highly specific for acute cholangitis, it's not very sensitive, with only about 5-7% of patients presenting with all five signs 1. Therefore, clinicians should maintain a high index of suspicion even if not all signs are present.
The pathophysiology of acute cholangitis, as reflected in Charcot's Pentad, involves biliary obstruction leading to bacterial proliferation in the bile, causing inflammation (pain and fever), systemic infection (fever, hypotension), and liver dysfunction (jaundice, altered mental status) 1. Prompt recognition and treatment are essential to prevent progression to septic shock and multiorgan failure. According to the 2017 WSES guidelines for management of intra-abdominal infections, the key elements of therapy in acute cholangitis are adequate antimicrobial treatment and biliary decompression to restore biliary drainage in case of obstruction 1.
The treatment of choice for biliary decompression in patients with moderate/severe acute cholangitis is endoscopic retrograde cholangiopancreatography (ERCP) 1. ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis, and it is recommended as the first-line treatment for biliary decompression 1. Percutaneous transhepatic cholangiography (PTC) should be reserved for patients in whom ERCP fails, and open drainage should only be used in patients for whom endoscopic or percutaneous trans-hepatic drainage is contraindicated or those in whom it has been unsuccessfully performed 1.
From the Research
Characteristics of Charcot's (Cholangitis) Pentad
- Charcot's triad, which is seen in 50%-70% of patients, consists of fever, right upper quadrant abdominal pain, and jaundice 2
- The five symptoms of fever, right upper quadrant abdominal pain, jaundice, altered mental status, and hypotension are referred to as Reynold's Pentad 2, 3
- Fever is seen in over 90% of cases, pain is seen in 70% of cases, and jaundice is seen in 60% of cases 2
- Altered mental status and hypotension are associated with severe cases of cholangitis 2
- Acute cholangitis can present in different ways, ranging from mild symptoms to fulminant sepsis 2, 4, 5, 6
Clinical Presentation
- The clinical presentation of acute cholangitis is characterized by fever, abdominal pain, and jaundice, which are the result of biliary obstruction and bacterial infection 4, 5, 6
- The diagnosis of acute cholangitis is commonly made by the presence of clinical features, laboratory tests, and imaging studies 6
- Prompt clinical recognition and accurate diagnostic workup, including adequate laboratory assessment and imaging, are critical steps in the management of cholangitis 3
Diagnosis and Management
- The treatment modalities for acute cholangitis include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 6
- Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes of the disease 6
- Specific recommendations for the diagnosis, classification, risk stratification, and treatment algorithms in acute bacterial cholangitis have been derived from the Tokyo guideline working group consensus 3