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Charcot's Triad

    Definition
    • The triad consists of fever, right upper quadrant (RUQ) pain, and jaundice
      • Fever: > 100.4
      • Abdominal pain: typically severe
      • Jaundice:
        • Normal direct bilirubin level: 0.1-0.3 mg/dL (1.71-5.13 mcmol/L)
        • Normal indirect bilirubin level: 0.2-0.7 mg/dL (3.42-11.97 mcmol/L)
        • Note: the yellow tint of the eyes/skin associated with jaundice is caused by yellow bile pigments accumulating in the blood which are eventually deposited in the skin  
    Etiology
    • Acute cholangitis (inflammation of the wall of bile ducts; usually caused by bacterial infection of the lumen)  
    Anatomy
    • Bile: an alkaline solution containing bile salts, bile pigments, cholesterol, triglycerides, phospholipids, and electrolytes; produced in the liver and stored in the gallbladder
    • Bile canaliculi: tiny canals that bile flows through toward the bile duct branches
    • Bile duct: fusion of the cystic duct and the common hepatic duct
    • Bilirubin: a yellow-pigmented waste product formed by the breakdown of erythrocytes; found in bile; removed from the body through elimination of feces
    • Common hepatic duct: composed of several bile ducts that fuse together; travels downward toward the duodenum
    • Cystic duct: drains the gallbladder
    • Portal triad: contains a branch of the hepatic artery, a branch of the hepatic portal vein, and a bile duct; located at each of the six corners of the right/left lobule  
    Pathophysiology
    1. Obstruction of bile flow
      1. Most commonly caused by choledocholithiasis (stones within the biliary tree) but can also be caused by surgery, tumors, indwelling stents/catheters, acute pancreatitis, and benign strictures
    2. Bacteria enters the biliary tract through the sphincter of Oddi
      1. Usual pathogens are: E. Coli, Klebsiella, Enterococci, Clostridium, and Bacteroides  
    Pearls
    • The additional presence of altered mental status and hypotension (known as Reynolds pentad) signifies acute suppurative cholangitis and is an endoscopic emergency
    • Bile duct obstruction lasting > 30 days results in liver damage leading to cirrhosis  
    Editors & Reviewers

    Editor:

    • Anthony J. Busti, MD, PharmD, FNLA, FAHA

    Last Reviewed: September 2016

    References
    1. Kumar V et al. Robbins Basic Pathology. 9th ed. Philadelphia, PA: Elsevier Saunders. 2013; 642.
    2. Lexi-Comp, Inc. (Lexi-DrugsTM ). Lexi-Comp, Inc.; 2013; Version 2.3.0
    3. Marieb EN, Hoehn K. Anatomy & Physiology. 3rd ed. San Francisco, CA: Pearson Benjamin Cummings. 2008; 802-806.
    4. Papdakis MA et al. Current Medical Diagnosis and Treatment. 53rd ed. McGraw-Hill Education; 2014; 643, 685-687.