Abdominal Pain Characteristics in Cholangitis
Cholangitis typically presents with right upper quadrant (RUQ) or epigastric abdominal pain that is steady in nature, often accompanied by fever/chills and jaundice—the classic Charcot's triad. 1, 2
Pain Location and Quality
The abdominal pain in cholangitis is characteristically located in the right upper quadrant or epigastrium, representing tenderness over the inflamed and obstructed biliary system 1, 2
The pain is steady rather than colicky, distinguishing it from simple biliary colic which tends to be more episodic 2, 3
Pain may radiate to the right shoulder or upper back, though this is less specific 4
Distinguishing Features from Other Biliary Conditions
The key distinguishing feature of cholangitis pain from acute cholecystitis is the presence of jaundice (indicating biliary obstruction) and the absence of Murphy's sign, though both conditions share RUQ pain and fever 1
Unlike biliary colic from simple choledocholithiasis, cholangitis pain is accompanied by systemic signs of infection including fever, chills, and laboratory evidence of inflammation 2, 5
Murphy's sign (inspiratory arrest during RUQ palpation) is typically absent in cholangitis but present in acute cholecystitis, making this a critical clinical distinction 1, 4
Clinical Context and Severity
The pain occurs in the setting of biliary obstruction, most commonly from common bile duct stones, but also from malignant strictures, benign strictures, or sclerosing cholangitis 5, 6
Severe cases may progress to Reynolds' pentad (Charcot's triad plus hypotension and altered mental status), indicating septic shock and requiring emergency biliary decompression 2, 6
The severity of pain correlates poorly with the presence of suppuration in the bile ducts; some patients with severe sepsis lack purulent bile, while others with suppurative bile may be only moderately symptomatic 6
Diagnostic Approach
Physical examination reveals RUQ tenderness without Murphy's sign, distinguishing it from cholecystitis 1, 4
Laboratory findings typically show elevated alkaline phosphatase, bilirubin, and leukocytosis, supporting the diagnosis when combined with clinical features 2, 5
Initial imaging with ultrasound is recommended to assess for biliary dilatation and obstruction, with MRCP reserved for cases requiring detailed visualization of the biliary tree 1, 4