Reynolds pentad (Charcot triad plus confusion and hypotension) means severe cholangitis: this is a biliary emergency needing urgent drainage and often critical care.
Diagnosis
- Charcot triad: fever or rigors, jaundice, RUQ pain
- Raised bilirubin, ALP and GGT (obstructive picture), raised inflammatory markers
- Dilated common bile duct with a stone or stricture on USS or MRCP
Causes
- Choledocholithiasis (commonest)
- Benign stricture or malignancy (pancreatic, cholangiocarcinoma)
- Post-ERCP or stent blockage
Grade I (mild)
- Charcot triad, responds to treatment
- IV antibiotics
- Elective biliary drainage
Grade II (moderate)
- High-risk markers, no organ failure
- ERCP drainage within 48 h
- Close monitoring
Grade III (severe)
- Organ dysfunction (Reynolds pentad)
- Resuscitate, critical care
- Urgent biliary drainage
Cholangitis bundle
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1. Sepsis care
Blood cultures then IV antibiotics within 1 hour per local policy (cover Gram-negatives and anaerobes). Fluids, and vasopressors or critical care if not responding.
Blood cultures then IV antibiotics within 1 hour per local policy (cover Gram-negatives and anaerobes). Fluids, and vasopressors or critical care if not responding.
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2. Imaging
USS first for duct dilatation and stones. MRCP if the diagnosis or anatomy is uncertain and the patient is stable.
USS first for duct dilatation and stones. MRCP if the diagnosis or anatomy is uncertain and the patient is stable.
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3. Biliary drainage
ERCP for stone extraction and stenting: urgently if severe or not responding, otherwise within 24 to 48 h. Percutaneous (PTC) drainage if ERCP fails.
ERCP for stone extraction and stenting: urgently if severe or not responding, otherwise within 24 to 48 h. Percutaneous (PTC) drainage if ERCP fails.
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4. Support and definitive care
Correct coagulopathy before intervention. After recovery, cholecystectomy for gallstone disease; treat strictures or malignancy.
Correct coagulopathy before intervention. After recovery, cholecystectomy for gallstone disease; treat strictures or malignancy.
Severity (Tokyo-style) markers
- Moderate: high WCC, high fever, age, bilirubin, low albumin
- Severe: organ dysfunction (hypotension, altered GCS, renal, hepatic, haematological)
- Severe disease needs urgent drainage
Pitfalls
- Waiting for MRCP before starting antibiotics in sepsis
- Delaying ERCP in a deteriorating patient
- Operating on an unstable septic patient (drain first)
- Missing a blocked stent as the cause
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026