Title : When pain slows the heart: An unusual case of cholecystitis with bradycardia
Abstract:
Bradycardia in the setting of abdominal pathology is an uncommon clinical finding. Cope’s sign - reflex bradycardia associated with acute cholecystitis (or cardio-biliary reflex) - is a rare but documented occurrence. Recognizing this atypical presentation is critical to avoid misdiagnosis, inappropriate management, and unnecessary cardiac workup.
The patient is a 44-year-old male who presented with progressive right upper quadrant abdominal pain, nausea, and vomiting for three days. Vital signs on admission revealed asymptomatic sinus bradycardia with a heart rate of 49 beats per minute, which was unexpected given the severity of pain (rated 10 out of 10 in intensity). Physical examination showed a positive Murphy's sign without peritoneal signs. Laboratory studies revealed leukocytosis, mild hyponatremia (135 mmol/L), and normal cardiac biomarkers and TSH. Electrocardiogram demonstrated sinus bradycardia of 39 beats per minute without ischemic changes. Computed tomography of the abdomen confirmed acute cholecystitis with cholelithiasis, a distended gallbladder, and mild pericholecystic inflammatory changes. Abdominal ultrasound showed cholelithiasis with gallbladder wall thickening. The patient was admitted, managed with intravenous fluids and antibiotics, and underwent laparoscopic cholecystectomy on day four of admission after cardiology evaluation and clearance. Notably, the bradycardia resolved shortly after pain was controlled. No underlying cardiac pathology was identified.
This case highlights Cope’s sign - a rare vagally mediated reflex bradycardia due to gallbladder inflammation. While acute pain and systemic inflammation often trigger tachycardia, visceral afferent stimulation can paradoxically increase vagal tone, resulting in bradycardia. Recognizing Cope’s sign in patients with abdominal pain can help avoid unnecessary diagnostic testing or misattributing the bradycardia to a primary cardiac pathology.
However, in patients presenting with severe or symptomatic bradycardia, heart block, or risk factors for conduction system disease, it is essential to distinguish Cope’s sign from intrinsic cardiac conditions. Reflex-mediated bradycardia may coexist with or obscure serious underlying heart block, especially in elderly or comorbid patients. In such cases, further cardiac evaluation is warranted before attributing bradycardia solely to a vagal reflex. This distinction is crucial, as missed cardiac pathology could lead to delayed treatment of life-threatening arrhythmias.
This case emphasizes the importance of maintaining a broad differential when evaluating bradycardia in the setting of abdominal pathology and reinforces the need to correlate autonomic signs with both abdominal and cardiac findings. Awareness of Cope’s sign can facilitate timely diagnosis of acute cholecystitis and prevent mismanagement of a rare but reversible cause of bradycardia.
