A Case Series of Cardio-Biliary Reflex Presenting as High-Grade Atrioventricular Block in Acute Cholecystitis

Abstract

Cardio-biliary reflex (CBR), also known as Cope’s sign, is a rare vagally mediated reflex phenomenon in which gallbladder pathology presents as acute cardiac rhythm disturbances. Although sinus bradycardia is the most commonly described manifestation, higher-grade atrioventricular conduction abnormalities are reported and may mimic primary cardiac pathology, resulting in a diagnostic dilemma and delays in management.
We describe a series of three patients who presented to the emergency department with acute abdominal pain associated with syncope, hypotension, and significant electrocardiographical abnormalities in the setting of acute cholecystitis. Electrocardiographic findings included complete heart block in two patients (case 1 and 3) and second-degree atrioventricular block (Mobitz type II) in one patient (case 2). Despite hemodynamic instability, the cardiac biomarkers, echocardiography, and electrolyte profiles were unremarkable in all three cases. Point-of-care ultrasonography and computed tomography subsequently identified underlying biliary pathology, including acute calculous and acalculous cholecystitis. Clinical improvement in heart rate and hemodynamic status occurred following analgesia and management of the underlying gallbladder disease, supporting the diagnosis of cardio-biliary reflex.
This case series highlights the importance of recognising cardio-biliary reflex as a reversible extracardiac cause of severe bradyarrhythmias and conduction disturbances.
Prompt identification of this phenomenon by treating physicians may help avoid unnecessary invasive cardiac interventions and facilitate timely identification of underlying biliary disease in patients.