SHARE @ Advocate Health - Midwest - Scientific Day: A Tried-and-True Triad? A Case Series of ‘Atypical Cholangitis’
 

Affiliations

Aurora Sinai Medical Center

Abstract

Introduction/Background:

Acute cholangitis is a serious infection of the biliary tree with dire implications if not recognized early including up to 50% mortality. The classic triad of fever, right upper quadrant (RUQ) pain, and jaundice developed by Jean-Martin Charcot is often relied on to identify these patients. Acute cholangitis, however, can be missed or misdiagnosed when relying solely on these criteria. Our case series demonstrates a heterogeneous sample of patients who did not fulfill the classic criteria for acute cholangitis but indeed had cholangitis. Our aim is to emphasize the atypical nature of some cases to consider expanding or reforming Charcot’s Triad.

Description:

We reviewed the cases of 5 (3 F and 2 M) patients with a mean age of 51.2 years who were diagnosed with acute cholangitis but did not fulfill the classical triad of fever, jaundice, and RUQ pain. Patient 1: 70-year-old female who presented with fever but no RUQ pain or jaundice. Occult infection was suspected. ERCP showed a retained stone and pus in the proximal bile duct and was managed by sphincterotomy, stone removal, and intravenous (IV) antibiotics. Patient 2: 56-year-old male who presented with RUQ pain without fever or jaundice. ERCP showed common bile duct (CBD) stone with upstream purulent material. He was managed with IV antibiotics, sphincterotomy, stone extraction, stent placement, and cholecystectomy. Patient 3: 31-year-old female who presented with RUQ pain without fever or jaundice. ERCP showed pus flowing from the ampulla and numerous stones in the CBD. She was managed by IV antibiotics as well as sphincterotomy, stone extraction, and stent placement. Patient 4: 66-year-old male who presented with fever and jaundice but denied RUQ pain. ERCP showed bulging ampulla and pus flowing right after cannulation. Multiple stones and sludge were seen in the CBD. He was managed with IV antibiotics, sphincterotomy, stone extraction, and stent placement. Patient 5: 33-year-old female patient who presented with RUQ pain but no fever or jaundice. ERCP showed numerous stones and pus in the CBD with a dilated biliary system. She was managed with IV antibiotics, sphincterotomy, stone extraction, and stent placement.

Discussion:

Patients with acute cholangitis can present with a variety of symptoms that do not consistently fulfill Charcot’s triad. Care should be taken to apply these criteria as appropriate but to also consider expanding the classic definition of cholangitis.

Presentation Notes

Presented at Scientific Day; May 21, 2025; Park Ridge, IL.

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Poster


 

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May 21st, 11:41 AM May 21st, 1:15 PM

A Tried-and-True Triad? A Case Series of ‘Atypical Cholangitis’

Introduction/Background:

Acute cholangitis is a serious infection of the biliary tree with dire implications if not recognized early including up to 50% mortality. The classic triad of fever, right upper quadrant (RUQ) pain, and jaundice developed by Jean-Martin Charcot is often relied on to identify these patients. Acute cholangitis, however, can be missed or misdiagnosed when relying solely on these criteria. Our case series demonstrates a heterogeneous sample of patients who did not fulfill the classic criteria for acute cholangitis but indeed had cholangitis. Our aim is to emphasize the atypical nature of some cases to consider expanding or reforming Charcot’s Triad.

Description:

We reviewed the cases of 5 (3 F and 2 M) patients with a mean age of 51.2 years who were diagnosed with acute cholangitis but did not fulfill the classical triad of fever, jaundice, and RUQ pain. Patient 1: 70-year-old female who presented with fever but no RUQ pain or jaundice. Occult infection was suspected. ERCP showed a retained stone and pus in the proximal bile duct and was managed by sphincterotomy, stone removal, and intravenous (IV) antibiotics. Patient 2: 56-year-old male who presented with RUQ pain without fever or jaundice. ERCP showed common bile duct (CBD) stone with upstream purulent material. He was managed with IV antibiotics, sphincterotomy, stone extraction, stent placement, and cholecystectomy. Patient 3: 31-year-old female who presented with RUQ pain without fever or jaundice. ERCP showed pus flowing from the ampulla and numerous stones in the CBD. She was managed by IV antibiotics as well as sphincterotomy, stone extraction, and stent placement. Patient 4: 66-year-old male who presented with fever and jaundice but denied RUQ pain. ERCP showed bulging ampulla and pus flowing right after cannulation. Multiple stones and sludge were seen in the CBD. He was managed with IV antibiotics, sphincterotomy, stone extraction, and stent placement. Patient 5: 33-year-old female patient who presented with RUQ pain but no fever or jaundice. ERCP showed numerous stones and pus in the CBD with a dilated biliary system. She was managed with IV antibiotics, sphincterotomy, stone extraction, and stent placement.

Discussion:

Patients with acute cholangitis can present with a variety of symptoms that do not consistently fulfill Charcot’s triad. Care should be taken to apply these criteria as appropriate but to also consider expanding the classic definition of cholangitis.

 

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