Charcot's Triad for Cholangitis
The classic triad for cholangitis, known as Charcot's triad, consists of fever, right upper quadrant abdominal pain, and jaundice. 1
The Three Components
The cardinal features that define acute cholangitis are:
Fever and/or chills: This is the most common presenting symptom of acute cholangitis, occurring in approximately 95% of patients 1, 2
Right upper quadrant or epigastric abdominal pain: This component is present in approximately 67% of patients with acute cholangitis 1, 2
Jaundice: This sign of biliary obstruction occurs in approximately 86% of patients and represents the visible manifestation of elevated bilirubin from biliary obstruction 1, 2
Clinical Recognition Pitfalls
Not all patients present with the complete triad—in fact, many do not. 3 This is a critical pitfall in clinical practice. When not all components of Charcot's triad are present, you can still make a definitive diagnosis by obtaining laboratory data showing cholestatic liver biochemistry (elevated alkaline phosphatase and γ-glutamyl transpeptidase) and imaging findings demonstrating biliary obstruction 4, 1
Reynolds' Pentad
In severe cases, the triad expands to Reynolds' pentad, which adds:
- Altered mental status/confusion
- Septic shock/hemodynamic instability 5
These additional features indicate severe (grade III) cholangitis requiring urgent biliary decompression within hours rather than the 24-hour window acceptable for moderate disease 1
Diagnostic Approach Beyond the Triad
Once you suspect cholangitis based on clinical presentation:
Laboratory evaluation: Obtain cholestatic liver enzymes (ALP, GGT), bilirubin, AST/ALT, and in critically ill patients add CRP, PCT, and lactate to assess sepsis severity 1, 6
Imaging: Start with abdominal ultrasound to detect biliary dilation, though it may be normal in early disease; follow with CT or contrast-enhanced MRCP for definitive visualization of the obstruction 1, 6
Immediate management: Initiate broad-spectrum antibiotics within 1 hour for septic patients and arrange for endoscopic biliary drainage, which is first-line treatment 1