From the Guidelines
Pentad cholangitis, also known as Reynolds' pentad, is a severe form of acute cholangitis that requires immediate medical attention and treatment with aggressive fluid resuscitation, broad-spectrum antibiotics, and urgent biliary decompression. The condition is characterized by five clinical signs: fever, jaundice, right upper quadrant abdominal pain, shock, and altered mental status, which represents a life-threatening emergency. According to the EASL clinical practice guidelines on sclerosing cholangitis 1, the diagnosis of large duct PSC should be made in the presence of typical findings of sclerosing cholangitis on high-quality cholangiography and after exclusion of secondary causes. The preferred diagnostic test is magnetic resonance cholangiopancreaticography (MRCP), which has a pooled sensitivity and specificity of 86% and 94%, respectively, for the diagnosis of PSC 1. Some key points to consider in the management of pentad cholangitis include:
- Aggressive fluid resuscitation to address hypotension
- Broad-spectrum antibiotics such as piperacillin-tazobactam or a combination of ceftriaxone and metronidazole to cover gram-negative and anaerobic organisms
- Urgent biliary decompression via ERCP, PTC, or surgical decompression
- Close monitoring in an intensive care setting with frequent vital sign checks, fluid balance assessment, and laboratory monitoring It is also important to note that pruritus is a common symptom in patients with sclerosing cholangitis, and pharmacological treatment with bezafibrate or rifampicin is recommended for moderate to severe pruritus 1. The treatment of pentad cholangitis should prioritize the management of the underlying biliary obstruction and infection, as well as the prevention of further complications and improvement of quality of life. In terms of specific treatment options, the guidelines recommend excluding relevant bile duct strictures in large duct sclerosing cholangitis as the cause of progressive pruritus, and treating relevant strictures with endoscopic balloon dilation or stenting after brushing 1. Overall, the management of pentad cholangitis requires a comprehensive approach that takes into account the underlying pathophysiology, clinical presentation, and treatment options, with the goal of improving morbidity, mortality, and quality of life.
From the Research
Definition and Symptoms of Cholangitis
- Cholangitis is a life-threatening infection of the biliary tract, which can be acute or chronic 2, 3.
- The symptoms of cholangitis can include fever, abdominal pain, and jaundice (Charcot's triad), as well as confusion and septic shock (Reynolds' pentad) 4.
- Reynolds' pentad is a set of symptoms that includes fever, abdominal pain, jaundice, confusion, and septic shock, which can occur in patients with severe cholangitis 4.
Diagnosis and Treatment of Cholangitis
- Diagnosis of cholangitis is typically made based on clinical features, laboratory tests, and imaging studies 5.
- Treatment of cholangitis usually involves administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct 5.
- Antibiotics such as piperacillin/tazobactam can be effective in treating cholangitis, especially in cases where the infection is caused by Gram-positive or Gram-negative aerobic bacteria and anaerobic bacteria 6.
Importance of Early Recognition and Treatment
- Early recognition and treatment of cholangitis are crucial to prevent unwanted clinical outcomes and improve patient outcomes 2, 5.
- Delayed treatment can lead to severe complications, including septic shock and death 2, 4.
- Prompt clinical recognition and accurate diagnostic workup, including adequate laboratory assessment and imaging, are critical steps in the management of cholangitis 4.