Symptoms of Cholangitis
Acute cholangitis classically presents with Charcot's triad: fever with chills, jaundice, and right upper quadrant abdominal pain. 1, 2, 3
Classic Clinical Presentation
The diagnosis of acute cholangitis requires a combination of clinical signs, laboratory findings, and imaging evidence of biliary obstruction. 1, 2
Charcot's Triad (Classic Presentation)
- Fever and chills - the most consistent symptom 1, 3, 4
- Jaundice - visible yellowing of skin and sclera 1, 2, 3
- Right upper quadrant abdominal pain 1, 2, 3
Important caveat: The complete Charcot's triad is now seen less frequently than historically described, particularly in patients with indwelling biliary tubes or those who have undergone prior biliary manipulation. 5 Many modern cases present with incomplete symptom complexes. 5
Reynolds' Pentad (Severe Disease)
In cases of severe acute cholangitis with septic shock, patients may additionally present with: 3, 4
Laboratory Findings
While not symptoms per se, these laboratory abnormalities accompany the clinical presentation and support the diagnosis: 1, 2
- Indicators of inflammation: leukocytosis, elevated C-reactive protein 1, 2, 5
- Indicators of biliary stasis: elevated alkaline phosphatase (most common biochemical abnormality), elevated gamma-glutamyltransferase (GGT), elevated bilirubin 1, 2, 6
- Elevated aminotransferases 6
Atypical Presentations
Critical pitfall: Patients with indwelling biliary tubes may develop cholangitis without significant jaundice, making the diagnosis more challenging. 5 Additionally, episodes of acute cholangitis are uncommon initial presentations in the absence of prior biliary surgery or instrumentation such as ERCP. 6
Physical Examination Findings
Beyond the symptoms, physical examination may reveal: 6
- Jaundice (visible on examination) 6
- Hepatomegaly (in approximately half of symptomatic patients) 6
- Splenomegaly (in approximately half of symptomatic patients) 6
Imaging Confirmation Required
The clinical and laboratory findings must be accompanied by imaging evidence of: 1, 2
Abdominal ultrasound is the recommended initial imaging modality to confirm biliary obstruction and identify the underlying cause. 1, 2, 7