Reynolds' pentad

Overview

Reynolds' pentad is a clinical syndrome that signifies a severe and potentially life-threatening form of acute cholangitis, a bacterial infection of the biliary tract. It consists of five specific signs and symptoms that indicate the progression of the infection to sepsis with multi-organ involvement. The pentad includes:

• Fever

• Right upper quadrant abdominal pain

• Jaundice

• Hypotension

• Altered mental status

Reynolds’ pentad is an extension of Charcot’s triad (fever, right upper quadrant pain, and jaundice) and suggests the presence of suppurative cholangitis or septic shock due to biliary obstruction. Prompt recognition and urgent intervention are critical, as the condition carries a high risk of morbidity and mortality if left untreated.

Causes

Reynolds' pentad arises as a complication of acute cholangitis, which itself is typically caused by obstruction and subsequent infection of the bile ducts. The blockage allows bacteria to ascend from the duodenum and multiply in the stagnant bile, leading to inflammation, infection, and eventually sepsis.

Common Causes of Biliary Obstruction:

• Gallstones: The most frequent cause, especially in the common bile duct (choledocholithiasis)

• Biliary strictures: Often due to previous surgery or inflammation

• Malignancy: Cholangiocarcinoma or pancreatic head cancer

• Biliary stents or catheters: Infections may develop in patients with indwelling biliary devices

• Parasitic infections: Such as liver flukes in endemic regions

Risk Factors:

• History of gallstones or cholecystectomy

• Biliary surgery or instrumentation (e.g., ERCP)

• Older age

• Immunosuppression

• Diabetes mellitus

Symptoms

Reynolds' pentad consists of five key clinical features that suggest advanced, systemic involvement of biliary infection. These symptoms may develop over hours to days and signal a medical emergency.

The Five Components of Reynolds' Pentad:

1. Fever and chills: Indicative of systemic infection

2. Right upper quadrant abdominal pain: Typically sharp and constant, due to biliary tract inflammation

3. Jaundice: Yellowing of the skin and eyes caused by elevated bilirubin levels

4. Hypotension: Low blood pressure resulting from sepsis or dehydration

5. Altered mental status: Confusion, disorientation, or lethargy from septic encephalopathy

Associated Findings:

• Nausea and vomiting

• Tachycardia (rapid heart rate)

• Dark urine and pale stools

• Signs of septic shock in advanced cases (cold extremities, weak pulse)

Diagnosis

Diagnosis of Reynolds' pentad requires a high index of suspicion based on clinical symptoms, supported by laboratory and imaging studies to confirm cholangitis and identify biliary obstruction.

Clinical Assessment:

• Detailed history of symptoms and risk factors

• Physical examination showing right upper quadrant tenderness, fever, and jaundice

Laboratory Investigations:

• Complete blood count (CBC): Elevated white blood cells (leukocytosis)

• Liver function tests (LFTs): Elevated bilirubin, alkaline phosphatase (ALP), and transaminases (ALT, AST)

• Blood cultures: Often positive for Gram-negative bacteria such as E. coli or Klebsiella

• Coagulation profile: May be abnormal in advanced liver involvement or sepsis

Imaging Studies:

• Ultrasound: First-line imaging; may show dilated bile ducts or gallstones

• CT scan: Helps identify abscesses or complications

• MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive view of biliary anatomy

• ERCP (Endoscopic Retrograde Cholangiopancreatography): Diagnostic and therapeutic; used to confirm and relieve biliary obstruction

Treatment

Reynolds' pentad is a medical emergency requiring prompt hospitalization, supportive care, broad-spectrum antibiotics, and biliary decompression. Delay in treatment can lead to septic shock, multi-organ failure, and death.

Initial Management:

• Hospitalization in ICU: For hemodynamic monitoring and intensive care

• IV fluids: To stabilize blood pressure and correct dehydration

• Broad-spectrum IV antibiotics: Targeting Gram-negative and anaerobic organisms (e.g., piperacillin-tazobactam, ceftriaxone with metronidazole)

• Vasopressors: If hypotension persists despite fluid resuscitation

Definitive Therapy – Biliary Decompression:

• ERCP with sphincterotomy and stent placement: The preferred method to relieve obstruction and drain bile

• Percutaneous transhepatic biliary drainage (PTBD): Alternative if ERCP is not feasible

• Surgical intervention: Reserved for cases where endoscopic or percutaneous methods fail

Supportive Care:

• Monitoring of renal and liver function

• Correction of coagulopathy if present

• Oxygen supplementation or mechanical ventilation if respiratory failure occurs

Prognosis

The prognosis of Reynolds' pentad depends on the timeliness and effectiveness of intervention. With prompt diagnosis and appropriate treatment, many patients recover fully. However, the condition has a high mortality rate if left untreated or if treatment is delayed.

Complications can include:

• Septic shock

• Multi-organ failure

• Acute kidney injury

• Recurrent cholangitis

• Biliary strictures or abscesses

Prognostic outcomes improve significantly with early biliary drainage and supportive critical care. Long-term management includes identifying and addressing the underlying cause of biliary obstruction to prevent recurrence, such as gallstone removal or treatment of malignancies.