Fever, jaundice and right upper quadrant pain; add hypotension and confusion for the pentad
Mnemonic
Charcot’s triad for ascending cholangitis, then add two for Reynolds:
- Fever with rigors
- Right upper quadrant pain
- Jaundice
Reynolds’ pentad adds:
- Hypotension
- Confusion
“Three for cholangitis, five for septic shock”, and the pentad indicates suppurative cholangitis requiring urgent biliary decompression by ERCP, not simply antibiotics.
The distinction from cholecystitis is the jaundice: cholecystitis gives fever and pain with a positive Murphy’s sign but is not usually jaundiced, because the obstruction is at the cystic duct rather than the common bile duct.
Charcot’s name attaches to several triads; the other commonly examined one is the triad of multiple sclerosis: nystagmus, intention tremor and scanning speech.
Expansion
Charcot’s triad - ascending cholangitis:
- Fever with rigors
- Jaundice
- Right upper quadrant pain
Reynolds’ pentad - adds two features of septic shock:
- Hypotension
- Confusion
The anatomy explains the danger. The biliary tree is a closed system draining into the duodenum. When it is obstructed and infected, pressure rises above the secretory pressure of the hepatocytes, and bacteria are forced from the ducts directly into the hepatic sinusoids and the bloodstream, cholangiovenous reflux.
That is why antibiotics alone are insufficient: the pressure must be relieved, by ERCP and sphincterotomy, percutaneous drainage or surgery.