Clinical features

The clinical features of cholangitis include:

• Charcot's triad: all three symptoms are observed in about 50–70 % of patients
  • right upper quadrant pain (biliary colic)
  • fluctuating jaundice
  • swinging pyrexia (usually with rigors)
• additionally, Charcot’s triad plus hypotension and a decreased level of consciousness (Reynolds’ pentad) can be observed in a more severe form of acute cholangitis in septic shock
• leucocytosis
• raised serum bilirubin and alkaline phosphatase
• bacteraemia - involving the common bile organisms, in decreasing frequency, E. coli, Klebsiella, Pseudomonas, enterococci, and Proteus, and in about 25% of cases, Bacteroides fragilis and Clostridium perfringens.

Notes:

• Charcot's triad - less than one-third of patients present with this classical clinical picture
• the majority of patients have fever
• about two-thirds have jaundice; pain, if present, is often mild
• acute cholangitis is more common in older people but can be difficult to diagnose
  • older patients may present with non-specific features such as confusion and malaise, without specific symptoms localised to the biliary tract

Reference:

1. Kiriyama S, Kozaka K, Takada T, et al. Tokyo guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):17-30.