Charcot's Triad of Ascending Cholangitis: Symptoms and Treatment
The classic triad of ascending cholangitis consists of right upper quadrant pain, fever, and jaundice, and treatment requires prompt antibiotic therapy and biliary decompression to prevent progression to septic shock and death. 1
Clinical Presentation
Classic Symptoms (Charcot's Triad)
- Right upper quadrant or epigastric abdominal pain (67-100% of cases) 1, 2
- Fever and/or chills (95% of cases) 3, 1
- Jaundice (86% of cases) 3, 1
Additional Clinical Findings
- Reynolds' pentad (Charcot's triad plus hypotension and altered mental status) indicates severe cholangitis with septic shock 1
- Leukocytosis and abnormal liver function tests are common laboratory findings 2
- Obstructive pattern of liver function tests (elevated alkaline phosphatase, bilirubin, gamma glutamyl transpeptidase) 4
Diagnosis
Laboratory Evaluation
- Serum liver biochemistry tests showing cholestatic pattern with raised alkaline phosphatase (ALP) and γ-glutamyl transpeptidase (GGT) 5
- Elevated serum bilirubin (direct and indirect) 5
- Elevated AST and ALT may be present 5
- In critically ill patients, elevated CRP, PCT, and lactate levels help evaluate severity of acute inflammation and sepsis 5
Imaging Studies
- Abdominal triphasic CT as first-line diagnostic imaging to detect intra-abdominal fluid collections and ductal dilation 5
- Contrast-enhanced MRCP to obtain exact visualization, localization, and classification of biliary obstruction 5
- Ultrasound may be used as initial investigation, especially in patients with suspected acute cholecystitis 5
Severity Assessment
Severity Classification
- Mild (Grade I): Responds to initial medical treatment with improved clinical findings 1
- Moderate (Grade II): No organ dysfunction but does not respond to initial medical treatment 1
- Severe (Grade III): Accompanied by at least one new-onset organ dysfunction 1
Treatment
Initial Management
Antibiotic Therapy
For non-critically ill and immunocompetent patients:
For critically ill or immunocompromised patients:
For patients with septic shock:
- Meropenem 1 g q6h by extended infusion or continuous infusion, or
- Doripenem 500 mg q8h by extended infusion or continuous infusion, or
- Imipenem/cilastatin 500 mg q6h by extended infusion 5
Biliary Drainage
- Percutaneous transhepatic biliary drainage (PTD) is effective in providing decompression as initial therapy for acute cholangitis 3
- Endoscopic retrograde cholangiopancreatography (ERCP) is an alternative approach for biliary decompression 7, 6
- Only a small percentage (5-10%) of patients with toxic cholangitis require emergency biliary decompression 2
Definitive Treatment
- After resolution of sepsis, definitive treatment depends on the underlying cause 3:
- Surgical intervention
- Internal/external drainage
- Balloon dilatation
- Other procedures based on the specific etiology
Etiology and Risk Factors
Common Causes
- Choledocholithiasis (historically the leading cause) 2
- Malignant biliary obstruction (pancreatic cancer, cholangiocarcinoma) 7
- Benign biliary strictures 6
- Iatrogenic causes (post-procedural, indwelling biliary tubes) 2
Complications and Prognosis
- Without prompt treatment, acute cholangitis can rapidly progress to septic shock with organ dysfunction 1
- Mortality is approximately 5% even with appropriate treatment 3
- Patients with end-stage malignant obstruction account for most deaths, while approximately 95% of patients survive an episode of cholangitis due to other causes 2
Clinical Pearls
- Early diagnosis and treatment are crucial to prevent progression to severe cholangitis 6
- The complete Charcot's triad is now seen less frequently, especially in patients with indwelling tubes who may develop cholangitis without significant jaundice 2
- The nature of the biliary obstruction may be the most important determinant of outcome 2