Symptoms of Cholangitis
The classic presentation of acute cholangitis includes fever with chills, jaundice, and right upper quadrant abdominal pain (Charcot's triad), though this complete triad is now seen less frequently in clinical practice. 1, 2
Core Clinical Features
The diagnosis of acute cholangitis requires evaluation of clinical signs, laboratory findings, and imaging studies 1, 3:
Primary Symptoms
- Fever and chills - the most consistent finding across all presentations 1, 4, 5
- Jaundice - cholestatic jaundice often accompanied by dark urine (choluria), pale stools (fecal acholia), and pruritus 1, 4
- Right upper quadrant abdominal pain - typically present but may vary in intensity 1, 2, 5
Extended Clinical Presentation (Reynolds' Pentad)
In severe cases, patients may progress to Reynolds' pentad, which adds 6:
Important Clinical Context
The complete Charcot's triad is now observed less frequently, particularly in patients with indwelling biliary tubes or those at tertiary referral centers. 2 Many patients with biliary stents or drains may develop cholangitis without significant jaundice because the obstruction is incomplete 2.
Additional Clinical Signs
- Nausea and vomiting 1
- Abdominal distension 1
- Hepatomegaly and splenomegaly - found in approximately half of symptomatic patients on physical examination 3
Laboratory Indicators
While not symptoms per se, these findings support the clinical diagnosis 1, 3:
- Leukocytosis - present in most patients 2, 5
- Elevated alkaline phosphatase - the most common biochemical abnormality 3
- Elevated aminotransferases 3
- Elevated bilirubin levels 5
- Inflammatory markers - elevated C-reactive protein and procalcitonin 1
Critical Clinical Pitfall
Patients may present with an insidious evolution featuring relapsing abdominal pain and recurrent cholangitis episodes, particularly when bile duct obstruction or stricture is not promptly identified. 1 This can lead to delayed diagnosis, sometimes occurring years after initial biliary injury, with progression to secondary biliary cirrhosis, portal hypertension, liver failure, and death if left untreated 1.