Classic Symptoms of Cholangitis
The classic presentation of cholangitis is Charcot's triad—fever, right upper quadrant abdominal pain, and jaundice—though this complete triad now appears in only 50-70% of patients, with fever being the most consistent finding. 1
Core Clinical Features
Charcot's Triad (Traditional Presentation)
- Fever and chills: The most consistent feature, frequently accompanied by rigors due to bacteremia from obstructed biliary system 1, 2
- Right upper quadrant abdominal pain: Reflects biliary distension and inflammation 1, 3
- Jaundice: Results from biliary obstruction, though may be absent in patients with partial obstruction or indwelling biliary tubes 4
Reynolds' Pentad (Severe Disease)
When cholangitis progresses to severe sepsis, patients may develop Reynolds' pentad, which adds two additional features to Charcot's triad:
- Altered mental status/confusion: Indicates septic encephalopathy 2
- Hypotension/shock: Reflects severe sepsis requiring vasopressor support 2
Important Clinical Context
Presentation Variations
- Incomplete triad is common: Many patients present with only fever and one other component, particularly in modern practice where biliary instrumentation is frequent 1, 4
- Episodes without prior intervention are uncommon: Cholangitis is unusual at initial presentation in the absence of prior biliary surgery or instrumentation such as ERCP 5
Physical Examination Findings
- Right upper quadrant tenderness: Common finding on palpation 1
- Hepatomegaly and splenomegaly: Present in approximately 50% of symptomatic patients at diagnosis 5
- Jaundice on examination: May be clinically apparent in patients with significant hyperbilirubinemia 5
Key Diagnostic Pitfalls
A critical caveat: Patients with indwelling biliary tubes or stents may develop cholangitis without significant jaundice, as drainage prevents complete obstruction 4. This makes fever and chills the most reliable indicators in this population.
History matters significantly: Recent biliary instrumentation or previous biliary surgery substantially increases cholangitis likelihood and should lower your diagnostic threshold, even when the complete triad is absent 1.
Laboratory Markers Supporting Clinical Diagnosis
- Leukocytosis: Present in most patients 4
- Elevated inflammatory markers: C-reactive protein and other acute phase reactants 1
- Cholestatic pattern: Elevated alkaline phosphatase, bilirubin (>2× upper limit of normal), and gamma-glutamyl transpeptidase 5, 6
- Elevated aminotransferases: Typically 2-3 times upper limits of normal, though may be markedly elevated in acute obstruction 5