P1150 - An Unusual Case of Acute Cholecystitis and Bradycardia (Cope's Sign)

Kanchi Patell, MD¹, Abdul Rahman Al Armashi, MD², Isaac Alsallamin, MD³, Francisco J. Somoza-Cano, MD¹, Omkar Desai, MD⁴, Keyvan Ravakhah, MD^1
1Saint Vincent Hospital, Cleveland, OH; ²Saint Vincent Hospital, Parma, OH; ³Saint Vincent Hospital, Westlake, OH; ⁴Yale University, Cleveland, OH

Introduction: Patients with acute cholecystitis present with right upper quadrant or epigastrium pain, nausea, and vomiting. Fever, leukocytosis, and a positive Murphy's sign support the diagnosis. Oftentimes, acute cholecystitis may mimic cardiovascular disease. Bradycardia is one of the rare presentations of cholecystitis and is called the "Cope's sign." Sir Zachary Cope was the first patient who presented with cardio-biliary reflex in 1970. Very few cases have been reported.

Case Description/Methods: A 55-year-old male presented with retrosternal chest pain, diaphoresis, and vomiting followed by epigastric pain. Symptoms started one night prior to admission and he thought they were attributed to the raw chicken he ate for dinner. Examination showed a diaphoretic man with abdominal tenderness and bradycardia. His symptoms were concerning because the chest pain and bradycardia were compatible with inferior-wall Ml. However, troponins were negative. EKG showed sinus bradycardia with 42 beats/min (Figure 1). To further aid investigation, abdominal US was ordered which revealed gallstones, pericholecystic fluid and gallbladder wall thickening. He was diagnosed as a case of acute cholecystitis which presented as a cardio-biliary reflex and bradyarrthythmia. He was treated with IV fluids, pain control, and antibiotics. Surgery recommended urgent cholecystectomy.

Discussion: Cardio-biliary reflex exists and can result in serious consequences. Bradyarrhythmia is the most common presentation of cardio-biliary reflex. Cardio-biliary reflex is believed to be vagally mediated and notably has been triggered by pain in the gallbladder via autonomic vagal innervations. A case-control study by Kaufman and Lubera reported that the increased vagal tone caused by the gallbladder could mimic myocardial infarction or cause bradyarrhythmia and even complete heart block. Patients with acute cholecystitis having abnormal ECG changes should be managed cautiously to avoid possible complications. This case highlights the rare case of acute cholecystitis with cope sign. Clinicians should have a high suspicion and order appropriate studies since these patietns can present as myocardial infarction.


Figure: Figure 1- EKG showed sinus bradycardia with 42 beats/min


Disclosures:
Kanchi Patell indicated no relevant financial relationships.
Abdul Rahman Al Armashi indicated no relevant financial relationships.
Isaac Alsallamin indicated no relevant financial relationships.
Francisco Somoza-Cano indicated no relevant financial relationships.
Omkar Desai indicated no relevant financial relationships.
Keyvan Ravakhah indicated no relevant financial relationships.


Kanchi Patell, MD¹, Abdul Rahman Al Armashi, MD², Isaac Alsallamin, MD³, Francisco J. Somoza-Cano, MD¹, Omkar Desai, MD⁴, Keyvan Ravakhah, MD¹. P1150 - An Unusual Case of Acute Cholecystitis and Bradycardia (Cope's Sign), ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.