Cholangitis denotes acute bacterial infection within the biliary tree, most commonly precipitated by obstruction from stones, strictures, or neoplasia. The spectrum ranges from mild ductal inflammation to life-threatening sepsis. Recognition of its cardinal features guides urgent biliary decompression and antimicrobial therapy.
Complication warnings
Persistent fever despite antibiotics, uncontrolled hypotension, or new-onset renal dysfunction suggests progressive sepsis and requires urgent endoscopic or percutaneous biliary drainage.
Charcot triad
Intermittent high spiking fever with rigors, constant right-upper-quadrant pain, and conjugated hyper-bilirubinaemia constitute the classical presentation seen in ~70 % of patients with incomplete or partial obstruction.
Reynolds pentad
Addition of hypotension (systolic BP < 90 mmHg) and altered mental status marks suppurative cholangitis with septic shock; this combination mandates emergency ductal drainage.
Jaundice and pruritus
Scleral icterus, dark urine, and clay-coloured stools reflect impaired bile flow; intractable pruritus results from cutaneous deposition of bile salts.
Tender hepatomegaly
The liver edge is hot, exquisitely painful to percussion, and may show a soft bulge over the obstructed segment; inspiratory arrest on palpation (Murphy sign) is frequent when concomitant acute cholecystitis is present.
Gastro-intestinal upset
Anorexia, nausea, and intermittent vomiting are common; large duct obstruction produces early satiety and eructation.
Systemic toxicity
Tachycardia > 100 beats min⁻¹, prolonged capillary refill, elevated lactate, and leukocytosis with left shift indicate bacteraemia and impending septic shock.
Laboratory cholestasis
Serum alkaline phosphatase and γ-glutamyl transferase rise early; total bilirubin climbs steadily as obstruction persists; blood cultures frequently yield enteric Gram-negative bacilli.
| Symptom / Sign | Typical Presentation |
|---|---|
| Charcot triad | Fever + RUQ pain + jaundice |
| Reynolds pentad | Above + hypotension + confusion |
| Jaundice | Conjugated, dark urine, pale stools |
| Tender hepatomegaly | Hot, painful edge, positive Murphy |
| GI upset | Nausea, vomiting, early satiety |
| Systemic toxicity | Tachycardia, leukocytosis, elevated lactate |
| Laboratory | ↑ ALP, ↑ GGT, ↑ bilirubin, positive blood cultures |
| Alarm signs | Refractory fever, shock, renal dysfunction |