Acute cholecystitis is condition where there is inflammation of
gallbladder and it can sometimes mimic heart disease and this can lead to
mismanagement of the condition. However no recent scientific study has been
done to look at this association and anecdotal references are mentioned in surgical literature. A
new publication by Michishige Ozeki and others from the Department of
Cardiology, Osaka Medical College has studied this association and the outcome.
They conducted a study to determine the
number of cases of acute cholecystitis being misdiagnosed as a cardiac event or
being accompanied by a cardiac pathology.
In a retrospective report they studied
5552 inpatients records and identified 16 patients who had been diagnosed with
acute cholecystitis after being admitted into the department of cardiology
during the four-year period from June 2010 - June 2014.
‘Cardiologist who admit patient with ECG & biomarker changes of heart disease to the ICU, must remember that acute cholecystitis too can give rise to similar changes and requires a different management strategy.’
The 16 patients were divided into two groups:
- It comprised of 5
patients who were initially diagnosed with a cardiac event and were later found
to have acute cholecystitis. Out of the 5 patients 4 came in with the complaint
of chest oppression and were given an initial diagnosis of acute coronary
while the remaining 1 patient came with complaint of loss of
consciousness and was thought to have Adams Stokes Syndrome
. Investigations showed that 2
of these patients had ECG changes, like T wave inversion and ST segment
depression, which mimicked myocardial
infarction, while the
other 3 showed elevated biomarker levels H-FABP (Heart-type fatty acid binding
protein) for myocardial injury. The final diagnosis was reached by symptoms of
fever and abdominal pain
, lab data suggestive of
inflammation, negative results on coronary Angiography
results on imaging studies, all indicative of acute cholecystitis.
- It comprised of 11
patients who showed both cardiac disease and acute cholecystitis, 2 of them
having been diagnosed at the time of admission and 9 developing it de-novo.
was the most
common coexisting condition involving 5 patients. They came with complaints of
chest/back pain with fever (or) abdominal pain (or) Dyspnea
of them were diagnosed with acute cholecystitis due to an incidental finding on
Treatment with antibiotics
helped resolve the issue in 2 cases
while the rest needed gall
Cardiologist who admit patient with ECG
& biomarker changes of heart disease to the ICU, must remember that
acute cholecystitis too
can give rise to similar changes and requires a different management strategy. According to the researchers this condition has been confused
with cardiac events on various occasions due to unusual ECG changes and
biomarker levels. The explanation of this association is as follows:
- There has been an indication that prolonged ICU
stay of patients of congestive heart failure may increase the risk of
- Biomarker H-FABP also increases in pulmonary embolism and hepatic injury.
- ECG changes may occur due to:
- Distension of bile duct may decrease coronary
- There might be a vagus mediated coronary
- There might be dehydration and electrolyte
imbalance due to inflammation.
Adams-Stokes Syndrome is a conduction defect in the heart where either
Mobitz II or 3rd
Degree Heart Block is complicated by ventricular
asystoles or sinoatrial disease. This leads to recurrent syncopal attacks.
Congestive heart failure
(CHF) is a condition in
which the heart fails to pump sufficient amount of blood and thus leads to
inadequate circulation. Mild to moderate congestion is either exercise induced
or appears only in stress conditions. Severe CHF refers to failure at rest and
is almost always fatal. There are various reasons for congestive cardiac
- There may be decreased contractility of the
- There may be obstruction to the ventricular
outflow (Pressure overload) due to conditions like aortic stenosis.
- There may be ventricular inflow obstruction due
to conditions like mitral stenosis.
- There might be volume overload on the ventricles
leading to inefficient pumping and increased demand.
- Arrhythmias may cause irregular heart beat
which lead to improper functioning of the heart.
- Diastolic dysfunction may occur
wherein the ventricles might not be able to pump sufficient blood in
conditions like constrictive pericarditis.
Cardiac troponins elevation and ECG data were also suggestive of ischemic coronary heart
disease in some cases. Ischemic heart disease refers to a condition in which
there is insufficient blood supply to the heart leading to a vicious cycle of
improper functioning and even less blood supply.
The research still has many limitations. Abdominal CT scan or ultrasound scanning
are not routinely done for all cardiac patients hence clinically silent cases
of acute cholecystitis may have been missed
. The cases which have developed
cholecystitis after discharge have not been recorded. Also, it is a
retrospective study with a small sample size and the surveillance of the
hepatobiliary system has been incomplete.
The research done thus provides a data
for further research which can help doctors tackle a potential threat of
misdiagnosis relating to cardiac diseases. This will help in early intervention
and proper treatment accordingly.
Davidson's Principles & Practice of
Medicine - 21st