Cholecystitis masquerading as cardiac chest pain: A case report

Abstract

Background: Cope’s sign is the association of bradycardia with symptoms of acute cholecystitis, which can occur due to a vagal cardiobiliary reflex. The clinical and electrocardiographic changes of bradycardia or complete heart block can mimic the presentation of acute coronary syndrome. This report highlights the unique possibility that bra-dycardia in patients with abdominal pain and gallstones can be due to this reflex. A 46-year-old obese man with hyperlipidemia and gallstones presented with chest pain suggestive of cardiac ischemia. The initial electrocardiography (EKG) was normal, although the patient subsequently developed bradycardia and a 2nd-degree atrioventricular (AV) block. The results of further cardiothoracic investigations (including echocardiography and pharmacologic stress testing) were normal. An ultrasound of the abdomen revealed acute cholecystitis. After he underwent a laparoscopic cholecystectomy, the chest pain resolved com-pletely, and the EKG reverted to its normal sinus rhythm. Acute cholecystitis rarely presents with cardiac chest pain and EKG changes due to triggering of the vagal car-diobiliary reflex. Given this atypical presentation, patients often undergo invasive cardiac procedures in search of a nonexistent cardiac etiology coupled with the possibility of a missed diagnosis of cholecystitis. When cli-nicians consider a diagnosis of acute coronary syndrome in patients with bradycardia, T-wave inversion, and ST-segment elevation (especially in the inferior leads), they should add the possibility of intra-abdominal pa-thologies (including cholecystitis) in the differential diagnosis.