Ascending cholangitis is caused by bacterial infection of the biliary tract/ducts, typically by organisms that ascend from the intestine (hence the "ascending").
Ascending cholangitis typically occurs in the setting of an obstruction of the biliary tract. As bacteria from the GI tract traverse the sphincter of Oddi, even in small numbers, the presence of a foreign object or blockage can act as a nidus for bacterial colonization and infection.
Charcot's triad, consisting of jaundice, fever, and abdominal pain, is classically associated with ascending cholangitis.
Fever is one of the three signs/symptoms of Charcot's triad. This occurs due to bacterial infection and the subsequent release of cytokines.
Jaundice is one of the three signs of Charcot's Triad. This occurs due to a physical back up of bile, causing hepatocyte damage and conjugated hyperbilirubinemia. This is a type of obstructive jaundice.
Abdominal pain is one of the three components of Charcot's Triad. Ongoing inflammation due to the infection irritates biliary nociceptors. In addition, obstruction and distention of the gallbladder and biliary tree can be perceived as abdominal pain.
Charcot’s triad is a valuable tool on its own for evaluating patients with suspected cholangitis, but can be made more efficacious through the addition of two notable symptoms: Hypotension and altered mental status. This combination of five symptoms/signs is known as Reynold’s Pentad. Patients with these additional signs/symptoms typically have more severe disease.
Patients with severe acute cholangitis may present with hypotension due to extensive inflammation and bacteremia. This finding is highly concerning as it indicates severe disease.
Like hypotension, altered mental status in a previously healthy patient with acute cholangitis indicates severe disease.
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