Charcot and Reynold

Today i was with the upper GI fellow and the pager beeped. Called back and the ED’s asking for a consult for a ?cholangitis in a 68 y.o. female who had a cholecystectomy done in ‘87. I think they only had open chole’s done at that time! Can someone please verify this? hmm.

ANYWAY, this is the first time i’ve come across a patient with cholangitis and i wasn’t about to leave even though it was already 7pm. So we headed down to ED and saw her massive file. So here’s the story.

• PC: RUQ pain, guarding. multiple episodes of vomitting.
• HOPC: sudden onset today. lost lots of fluids. malaise.
• PMHx: parathyroidectomy (superior right gland), hypercalcaemia, ureteric colic
• O/E: slightly jaundice, tender RUQ, looks very unwell
• Rx: IV fluids, metranidazole, ceftriaxone, vit K, ERCP

The ERCP needed to be scheduled and i witnessed how fast consent can be obtained. The fellow took like 5seconds to write down complications of the ERCP (bleeding, infection, perforation, pancreatitis) and 30 seconds to explain them to the patient, got her to sign, and thats it. In fact, the bulk of it was her signing it as she was generally unwell! Geez! Screw the informed consent and legal blabla behind all that. Just do it and get over with it. Ok, i know why its important and stuff, but I don’t see why we needed to have 4 2hr tutorials in year 1, wasting my good afternoons in the pre-clinical phase of my medical education. That wasn’t the end; we get a 4-mark short answer questions asking us medico-legal stuff like “uUder what circumstances can informed consent be ignored/breached?” On with the clinical medicine please….

Charcot came up with his famous triad for acute ascending cholangitis which are RUQ pain, jaundice and fever. All present in this lady. I stated this triad to the fellow on the way to the ED and he questioned me further about the pentad. Too bad i forgot about the last one. I remembered something about CNS symptoms. Its septic shock!! Mr Fellow said they could be hypertensive (or hypo?) as well. Hmph.

Anyway, who’s Charcot and Reynold? What else was named after them? An interested medical student explores further:

Jean-Martin Charcot (29 November 1825 – 16 August 1893) was a French neurologist and professor of anatomical pathology. His work greatly influenced the developing fields of neurology and psychology. (Wiki) Other eponyms for Charcot include:

• Charcot’s artery (lenticulostriate artery)
• Charcot’s joint (diabetic arthropathy)
• Charcot’s disease (amyotrophic lateral sclerosis)
• Charcot-Marie-Tooth disease (peroneal muscular atrophy)
• Charcot Wilbrand syndrome (visual agnosia & loss of ability to revisualise images)
• Charcot’s intermittent hepatic fever (intermittent pain, intermittent fever, intermittent jaundice & loss of weight)
• Charcot-Bouchard aneurysms (tiny aneurysms of the penetrating branches of middle cerebral artery in hypertensives)

But wait! There’s ANOTHER Charcot’s triad. This neurological one is the combination of nystagmus, intention tremor, and scanning or staccato speech. Sometimes associated with multiple sclerosis but is not, however, as previously considered by some authors, pathognomonic for multiple sclerosis. (Wiki)

The 2 publications leading to the description of these symptoms related to cholangitis.

• J. M. Charcot:
  Leçons sur les maladies du foie, des voies biliaires et des reins faites à la Faculté de Médecine de Paris.
  Recueillies et publliées par Bourneville et Sevestre.
  Paris: Bureaux du Progrés Médical & Adrien Delahaye, 1877. 480 pages.
  English translation, New York, 1878.
  Referring to Désiré-Magloire Bourneville (1840-1909) and Louis-Arthur Sevestre (1843-1907).
• B. M. Reynolds, E. L Dargan:
  Acute obstructive cholangitis: a distinct clinical syndrome.
  Annals of Surgery, Philadelphia, 1959, 150: 299-303.