What is Charcot's triad and what is the recommended management for acute cholangitis?

Charcot's Triad in Acute Cholangitis

Charcot's triad consists of fever, jaundice, and right upper quadrant abdominal pain—the classic presentation of acute cholangitis that requires immediate antibiotic therapy and urgent biliary decompression to prevent life-threatening septic complications. 1, 2

Definition and Clinical Significance

Charcot's triad represents the three cardinal features of acute cholangitis:

• Fever and/or chills 3, 4
• Jaundice 3, 4
• Right upper quadrant or epigastric abdominal pain 3, 4

However, a critical pitfall is that not all patients present with the complete triad—when components are missing, diagnosis requires supporting laboratory data showing inflammation and imaging evidence of biliary obstruction 3. Recent research demonstrates that Charcot's triad alone has only 46% sensitivity, meaning it misses more than half of cholangitis cases, though it maintains 99% specificity 5.

Pathophysiology

Acute cholangitis develops from the combination of biliary obstruction plus bacterial infection—obstruction is the essential predisposing factor without which cholangitis cannot occur 6, 1. Choledocholithiasis (bile duct stones) is the most common cause 6, 4.

Diagnostic Approach

Use a combination of clinical features, laboratory findings, and imaging rather than relying solely on Charcot's triad 3:

Laboratory Findings:

• Elevated inflammatory markers (WBC, CRP) 1, 2
• Elevated bilirubin 1, 2
• Elevated alkaline phosphatase 1, 2

Imaging:

• Ultrasound is the initial imaging modality of choice, looking for biliary dilatation and evidence of obstruction (stones, stricture, mass) 1, 2
• If ultrasound is equivocal but clinical suspicion persists, proceed to CT scan with IV contrast 1

Management Algorithm

Immediate Initial Management (Within 1-6 Hours):

1. Antibiotic therapy within 1 hour for septic patients, within 6 hours for less severe cases 1
2. Fluid resuscitation 1
3. Correction of coagulopathies 1

Biliary Decompression (Within 24 Hours):

ERCP with stent placement is the procedure of choice for biliary decompression and should be performed within 24 hours of admission in grade 2 cholangitis to significantly reduce 30-day mortality 1, 2. Endoscopic transpapillary biliary drainage is first-line due to lower risk of adverse events compared to percutaneous or surgical drainage 1.

Alternative Drainage Options:

• Percutaneous transhepatic biliary drainage (PTBD) is reserved for ERCP failures (unsuccessful cannulation or inaccessible papilla), though it carries risks of biliary peritonitis, hemobilia, pneumothorax, and liver abscesses 6

Severity Grading

Classify severity into three grades to guide urgency of intervention 3:

• Grade III (Severe): Presence of new-onset organ dysfunction—requires immediate biliary drainage 3
• Grade II (Moderate): No organ dysfunction but fails to respond to initial medical treatment—requires early drainage within 24 hours 3
• Grade I (Mild): Responds to initial medical treatment with clinical improvement 3

Critical Pitfalls

Delayed intervention is associated with elevated morbidity and mortality, increased ICU admission rates, and prolonged hospitalization 6, 1. In severe cholangitis with organ dysfunction, early interventional biliary drainage is absolutely essential for survival 6.

ERCP-related complications include pancreatitis, hemorrhage, and post-ERCP cholangitis 1.