BRAIN AND BILIARY CHARCOT TRIAD: HISTORY, CONSIDERATIONS - MEDICINE - 2024

The Charcot triad is a medical criterion created in 1877 by French Dr. Jean-Martin Charcot. This doctor associated the appearance of three clinical manifestations for the presumptive diagnosis of two different clinical entities. The first is the cerebral triad, also known as (Charcot triad I) and the second corresponds to the biliary triad or (Charcot triad II).

The Charcot I or cerebral triad consists of three frequent signs in multiple sclerosis, these are: involuntary movements of the body (ataxia), involuntary movement of the eyes (nystagmus) or double vision (diplopia) and difficulty in emitting words in form continuous (scanned speech).

Schematic representation of the biliary and cerebral Charcot triad. Source: Prepared by the author MSc. Marielsa Gil. Image source: Bobjgalindo / pxhere / pixabay.com

Multiple sclerosis is an autoimmune neurodegenerative disease of the central nervous system. It is characterized by demyelination of nerve fibers and axonal damage, due to an inflammatory reaction. This results in atrophy of the CNS, with a dysfunction in the transmission of nerve impulses.

Meanwhile, the clinical manifestations that comprise the Charcot II or biliary triad are: the appearance of a yellow color in the skin and mucosa (jaundice), pain in the right hypochondrium, and fever syndrome.

It should be noted that the manifestations of the biliary triad are not exclusive to the disease, but the combination of the three suggests the suffering of a clinical picture known as cholangitis or biliary sepsis.

Cholangitis is a disease characterized by an obstruction of the common bile duct, also known as common bile duct. It is caused by inflammation and infection of the hepatic and bile ducts or by the complication of cholelithiasis (stones in the gallbladder).

It is a true medical emergency that requires the administration of antibiotics and surgical intervention.

History

Jean-Martín Charcot was a famous French doctor who brought much knowledge to medicine, thanks to his tireless investigative spirit. Most of his research was developed in the field of neurology and psychiatry, although he also touched other branches of medicine.

At the age of 37, he began his work as a researcher, in the neurology area of ​​the Hospital de la Salpêtrière. There he inaugurated a pathology laboratory where he would carry out all his research. He himself had microscopy and photography to study the lesions.

Charcot studied patients in life and also postmortem. With this, he was able to correlate the clinical manifestations of the patients in life and their respective pathological changes in post-mortem brain tissue.

He described innumerable neurological diseases, among which is the now known multiple sclerosis, but at the time it was called by Charcot sclérose en plaques disséminées (sclerosis spread in plaques).

Today it is known that this disease affects not only the brain, but also the spinal cord. For its diagnosis, she proposed as a criterion what was called the Charcot I triad or the cerebral Charcot triad.

Likewise, he described the Charcot II triad or biliary Charcot triad, for the diagnosis of biliary disease, called by him as "liver fever", being known today as "cholangitis".

Charcot triad I or cerebral

Charcot I triad, as its name indicates, comprises three clinical manifestations, which are associated with multiple sclerosis. The Charcot triad I comprises:

Ataxia or tremor

Involuntary movements of the body. There is an incoordination of movements in general. The patient is not able to control this situation. These movements affect the patient's gait.

Speak scanned

Difficulty articulating words. It is characterized by a difficult, torpid, interrupted and slow pronunciation. It is the product of atrophy of the central and peripheral nervous system.

Nystagmus or diplopia

The term nystagmus or nystagmus refers to involuntary movements of the eyeballs. These movements are usually highly variable in terms of frequency, direction and intensity. The movements can be circulatory, up and down, sideways, oblique, or a mixture of them.

Another frequent affectation is diplopia, which is a vision alteration characterized by duplicating the observed images (double vision).

Charcot II or biliary triad

Dr. Charcot also proposed a combination of three symptoms to define a condition that he called liver fever and is now known as acute cholangitis. The Charcot II or biliary triad comprises:

Jaundice

This term is used when a yellowish pigmentation is observed on the skin or mucous membranes of affected people. It occurs due to an increase in bilirubin in the blood. In cholangitis, bilirubin accumulates due to biliary obstruction, preventing it from being eliminated. This manifestation only occurs in two thirds of the patients with this pathology.

Abdominal pain

In cholangitis, pain may occur in the right upper quadrant of the abdomen, specifically in the right upper quadrant. The pain is recurrent, that is, it comes and goes with some frequency. The intensity of the pain can vary from episode to episode. The pain intensifies on palpation.

Pain in the right hypochondrium is an alert that guides where the problem originates. It is the second most frequent manifestation, it occurs in 70% of patients with cholangitis.

Febrile syndrome

The febrile syndrome that occurs in cholangitis not only manifests as an intermittent rise in the patient's body temperature, but is also characterized by the presence of chills and excessive sweating (diaphoresis). Obviously it is a very nonspecific clinical manifestation on its own.

Fever is the most frequent manifestation, and it can be observed in approximately 90% of patients with this pathology. Two thirds of patients with fever present with chills and 30% have hypotension, which manifests itself with excessive sweating.

Final thoughts

The sensitivity of the Charcot I or cerebral triad is very low. Only 15% of patients with multiple sclerosis manifest the triad. Specificity is also low, since these signs can occur in other pathologies.

That is why the guidelines that are currently internationally accepted for the diagnosis of multiple sclerosis are those proposed by McDonald.

These criteria were revised in 2017. In addition, there are also other resources that help in their diagnosis, such as the magnetic resonance study.

Magnetic resonance studies in patients with multiple sclerosis. Lesions with different locations. Source: DraazucenaDL

An early diagnosis is crucial in this disease, as it will help to place the appropriate treatment, delaying the progression of the disease.

For its part, the Charcot II triad is not exclusive to cholangitis, as it can also be observed in patients with cholecystitis and hepatitis. In this sense, although the Charcot II triad guides the diagnosis, it is also true that nowadays the diagnosis can be confirmed through a variety of studies.

The studies include laboratory tests (transaminases, alkaline phosphatase, white blood cell count, and bilirubin). As well as imaging studies, such as: ultrasound, computed tomography and magnetic resonance cholangiography.

On the other hand, it is important to emphasize that in 1959 the Reynolds pentad was proposed. Dr. Reynolds added two clinical manifestations to the Charcot II triad.

The added clinical manifestations were: presence of shock due to sepsis and depression of the central nervous system (mental confusion). Of course, Reynolds' pentad describes a much more serious condition, called “acute obstructive suppurative cholangitis”.

References

1. Camacho J. Charcot and his legacy to medicine. Medical Gazette of Mexico, 2012; 148: 321-326. Available at: medigraphic.com
2. "Multiple Sclerosis" Wikipedia, The Free Encyclopedia. 1 Aug 2019, 18:00 UTC. 24 Aug 2019, 22:56 en.wikipedia.org
3. "Charcot Triad" Wikipedia, The Free Encyclopedia. 20 Dec 2017, 14:25 UTC. 24 Aug 2019, 22:57 en.wikipedia.org
4. Kumar DR, Aslinia F, Yale SH, Mazza JJ. Jean-Martin Charcot: the father of neurology. Clin Med Res. 2011; 9 (1): 46–49. Available from: ncbi.nlm.nih.gov
5. Orellana P. Presentation, diagnosis and therapy of acute cholangitis. Med. Leg. Costa Rica. 2014; 31 (1): 84-93. Available from: scielo.
6. «Colangite acuta» Wikipedia, L'enccyclopedia libera. 25 mag 2019, 20:24 UTC. 25 Aug 2019, 03:52. Wikipedia.org.