Signs and Symptoms of Cholangitis
Acute cholangitis classically presents with Charcot's triad—fever, right upper quadrant abdominal pain, and jaundice—though this complete triad is now seen in only 50-70% of patients. 1, 2
Core Clinical Manifestations
Classic Charcot's Triad
- Fever (present in >90% of cases) 2
- Right upper quadrant abdominal pain (present in ~70% of cases) 2
- Jaundice (present in ~60% of cases) 2
Reynolds' Pentad (Severe Disease)
When patients present with all five of the following symptoms, this indicates severe or toxic cholangitis: 2
- Fever
- Right upper quadrant abdominal pain
- Jaundice
- Altered mental status
- Hypotension/shock
Additional Clinical Features
Common Associated Symptoms
Physical Examination Findings
- Right upper quadrant tenderness 1
- Fever with rigors (particularly suggestive of cholangitis due to obstructive disease, especially choledocholithiasis) 1
Laboratory Abnormalities
While not strictly "signs and symptoms," the diagnosis requires laboratory evidence: 1
- Leukocytosis (present in most patients) 3
- Elevated alkaline phosphatase and bilirubin (indicators of biliary stasis) 3, 4
- Markers of inflammation 1
Important Clinical Context
Evolving Presentation Patterns
The classic Charcot's triad is now seen less frequently than historically reported, particularly in tertiary referral centers. 3 This change reflects:
- Increasing cases related to nonoperative biliary manipulations 3
- Patients with indwelling biliary tubes who may develop cholangitis without significant jaundice 3
- Prior antibiotic treatment masking typical presentations 3
Severity Spectrum
Cholangitis presentations range from: 2, 5
- Mild symptoms with minimal systemic involvement
- Fulminant sepsis with shock and altered mental status
- The pace and severity of symptoms should guide urgency of diagnostic work-up and intervention 5
Critical Pitfall
A history of recent biliary instrumentation or previous biliary surgery significantly increases cholangitis likelihood and should lower your threshold for diagnosis, even with incomplete symptom presentation. 1, 2