Masri, Karim R

Salyers, William J

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Kansas Journal of Medicine 2012                                     Pentad’s Triad  94           Pentad’s Triad:  Revisiting Reynold’s Pentad Karim R. Masri, M.D.  William J. Salyers, M.D.  University of Kansas  School of Medicine-Wichita  Department of Internal Medicine    Introduction Acute cholangitis is a potentially life-threatening complication of choledocho-lithiasis. It is defined as a triad of fever, jaundice, and right upper quadrant pain, also known as Charcot’s Triad.1 Sequelae of acute cholangitis includes suppurative cholangitis, known as Reynold’s pentad.  Reynold’s pentad includes Charcot’s Triad, hypotension, and altered mental status.2 This report describes an unusual case of acute cholangitis in a patient who manifested three of the five findings of Reynold’s pentad.  Case Report An 88-year-old black woman presented with decreased oral intake, nausea, vomiting, and right upper quadrant pain that started two days prior to presentation.  Her mental status was normal. The patient denied any history of fever, chills, or sweats. No change was reported in bowel movement in the form of diarrhea, melena, or    hematochezia    and    no    hematemesis     occurred.  She was afebrile and normo-tensive with initial blood work showing a bilirubin of 4.7 mg/dL with a predominance of conjugated (2.9 mg/dL) versus unconjugated (1.8 mg/dL).  AST was 423 U/L, ALT 336 U/L, and alkaline phosphatase 271 U/L. The patient's white blood count was 11,800 cells/cmm. She also had a urinary tract infection.  A sonogram of the liver showed a 1.1 cm stone at the neck of the gallbladder without evidence of cholecystitis (Figure 1) and the common bile duct (CBD) was dilated up to 9 mm (Figure 2). She was started empirically on piperacillin/ tazobactam for possible acute ascending cholangitis. A surgical consult resulted in a magnetic resonance cholangiopancreato-graphy (MRCP) showing increased CBD dilatation to 1.4 cm. There was a 0.9 cm T2 hypointense focus at the ampulla of Vater, possibly representing a choledocholithiasis and a 0.9 cm stone at the gallbladder neck.                                                       Figure 1.  A 1.1 cm cholelithiasis at neck of Figure 2. Common Bile Duct is 0.9 cm.                 gallbladder.Kansas Journal of Medicine 2012                                     Pentad’s Triad  95  The patient had positive blood cultures growing gram-negative bacillus.  The blood culture grew Citrobacter freundii which was susceptible to piperacillin/tazobactam. With-in 25 hours of admission, her blood pressure dropped to 72/42 mmHg, requiring vaso-constrictors with norepinephrine and vaso-pressor, with a pulse of 102 bpm. The patient also developed worsening mental status and acute delirium.  A gastroenterologist was consulted and the   patient   was   taken   for   urgent  endo- scopic retrograde cholangiopancreatography (ERCP) less than 36 hours after admission. ERCP showed a filling defect representing choledocholithiasis obstructing the distal aspect of the common bile duct (Figure 3).  The INR was high (1.9) so a chole-cystectomy was not recommended. She was on vasopressor and antibiotics. The decision was made to place a 7Fr 10 cm biliary stent without performing a sphincterotomy.  Purulent drainage was seen upon stent deployment, followed by adequate bile flow (Figure 4). The next day, the patient’s mental status returned to baseline. She had developed a leukocytosis of 20,000 cells/ cmm. Her septic shock resolved off vasopressor agents and continued antibiotic therapy.     Figure 3.   ERCP  showing  9  mm  choledo- cholithiasis at distal CBD.   Figure 4. ERCP after stent placement bypassing choledocholithiasis at ampulla of Vater. Discussion This patient presented with acute cholangitis, which is a clinical diagnosis based on Charcot’s Triad: fever, jaundice, and right upper quadrant pain.1 Yet, our patient did not have fever or dermatologic evidence of jaundice, but she had icterus and a bilirubin level of 4.7mg/dL. Our patient was afebrile throughout her hospitalization. Interestingly, the elderly may not manifest fever during acute cholangitis.3 Our patient’s clinical course became complicated by hypotension with septic shock and decreased    mental status with delirium, which suggested Reynold’s pentad or suppurative cholangitis.4,5 We labeled the presentation of signs and symptoms as Pentad’s Triad because our patient truly manifested three of the five findings of Reynold’s pentad. Suppurative cholangitis may be associated with increased mortality, especially in the elderly population.6,7 Treatment involves blood pressure support, antibiotic management, and endoscopic choledocholithiasis retrieval Kansas Journal of Medicine 2012                                     Pentad’s Triad  96  with sphincterotomy or stent placement if stone retrieval and sphincterotomy is contra-indicated, such as in coagulopathies.8-10 In case of the latter, a second attempt is made when the clinical acuity defervesce.   References  1 Saik RP, Greenburg AG, Farris JM, Peskin GW. Spectrum of cholangitis. Am J Surg 1975; 130(2):143-150. PMID 1098507. 2 Kinney TP. Management of ascending cholangitis. Gastrointest Endosc Clin N Am 2007; 17(2):289-306, vi. PMID: 17556149. 3 Agarwal N, Sharma BC, Sarin SK. Endoscopic management of acute cholangitis in elderly patients. World J Gastroenterol 2006; 12(40):6551-6555. PMID: 17072990. 4 Boey JH, Way LW. Acute cholangitis.  Ann Surg 1980; 191(3):264-270. PMID: 7362292. 5 DenBesten L, Doty JE.  Pathogenesis and management of choledocholithiasis. Surg Clin North Am 1981; 61(4):893-907.  PMID: 7025299. 6 Sugiyama M, Atomi Y. Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch Surg 1997; 132(10):1129-1133. PMID: 9336 514. 7 Pitt HA, Cameron JL, Postier RG, Gadacz TR. Factors affecting mortality in biliary tract surgery. Am J Surg 1981; 141:66-72.  PMID: 6970004. 8 Sharma BC, Kumar R, Agarwal N, Sarin SK. Endoscopic biliary drainage by nasobiliary drain or by stent placement in patients with acute cholangitis.  Endoscopy 2005; 37(5):439-443. PMID: 15844022. 9 Leung JW, Chung SC, Sung JJ, Banez VP, Li AK. Urgent endoscopic drainage for acute suppurative cholangitis. Lancet 1989; 1(8650):1307-1309. PMID: 2566 834. 10 Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992; 326(24):1582-1586.  PMID: 1584258.  Keywords:  choledocholithiasis, cholangitis, case report  

Pentad’s Triad: Revisiting Reynold’s Pentad

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Pentad’s Triad: Revisiting Reynold’s Pentad

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