Chest pain as an atypical symptom of acute cholecystitis

Summary: Chest pain is one of the most common symptoms addressed in the internal emergency department and has a broad differential diagnosis. They can be of cardiac or non-cardiac origin. They are generally caused by diseases of the intrathoracic organs, possibly also organs of adjacent regions (neck and abdomen) and involvement of musculoskeletal structures of the chest wall. They often signal an acute, life- -threatening disease and therefore require prompt diagnosis with immediate causal therapy. The history revealed by these complaints is often not typical, they are usually not fully expressed, and even the patient himself is often unable to specify them well. The presented case report describes an interesting case of complicated acute cholecystitis, the initial symptom of which was chest pain with suspicion of acute pulmonary embolism. Physical findings in the abdomen were negative throughout, and inflammatory changes in the gallbladder were noted as an incidental finding on CT angiography, which excluded pulmonary embolism. On further investigation, subcapsular hematoma and hemoperitoneum were diagnosed. After transfer to a higher unit, perforation of the hepatic capsule at the border with the gallbladder bed was detected peroperatively. A cholecystectomy was performed with treatment of venous hemorrhage of the liver parenchyma. Histological description of the resection confirmed phlegmonous inflammation. This case report highlights the importance of differential diagnosis of other possible non-cardiac causes of chest pain, including consideration of unusual causes of ECG waveform changes and elevation of cardiac markers. Effective multidisciplinary collaboration is key as this is a life-threatening condition. Key words: cholecystitis – chest pain – Cope’s sign – ECG changes – bradycardia