acute cholecystitis refers to a syndrome of right upper quadrant pain , fever and leukocytosis associated with gallbladder inflammation that is usually related to gallstone disease .
patients with acute cholecystitis typically complain of abdominal pain , most commonly in the right upper quadrant or epigastrium .
. a variety of other conditions can give rise to symptoms in the upper abdomen , which may be confused with acute cholecystitis .
these include cardiac ischemia , which can usually be differentiated by the clinical setting in which it occurs and by obtaining the appropriate diagnostic studies , such as an electrocardiography ( ecg ) and laboratory examinations .
however , acute cholecystitis has also been reported to mimic the nonspecific diffuse ecg changes associated with ischemic heart disease .
studies have shown that gallbladder distension reduces coronary blood flow , providing a mechanism for the association of gallbladder disease , myocardial ischemia and st segment ecg changes .
various sources have also reported elevated troponin levels in patients with sepsis , septic shock or systemic inflammatory response syndrome , but the mechanism by which infection causes troponin release is not yet understood .
the finding of ecg changes , associated with elevation of the specific cardiac marker troponin , alarms many physicians and leads them to initiate diagnostic cardiac investigations for early confirmation and treatment of ischemic heart disease .
awareness of the differential diagnosis is crucial to ensure appropriate diagnostic investigations and to avoid incorrect cardiac management , such as thrombolysis and even angioplasty .
we present the case of a 75-year - old woman who presented at the accident and emergency department after 2 days of epigastric and right upper quadrant pain associated with nausea but without fever .
she had been referred for nonspecific digestive difficulties within the past few months and for a similar episode 1 week earlier .
the abdomen was tender , with guarding in the right upper quadrant and positive murphy 's sign .
abdominal ultrasound revealed gallbladder distension , wall thickening and a 2.5 cm stone in the gallbladder lumen that were suggestive of acute cholecystitis ( fig .
the following laboratory findings were obtained at admission : white blood cell count 8.3  10/l , c - reactive protein ( crp ) 85 mg / l , serum total bilirubin 17.3 mol / l , alkaline phosphatase 79 iu / l , aspartate aminotransferase 23
iu / l , lipase 32 iu / l , sodium 136 mmol / l , potassium 3.8 mmol / l , blood urea 5.1 mmol / l , creatinine 82 mol / l and troponin i < 0.01 u / l . the clinical diagnosis was acute cholecystitis .
ecg showed sinus rhythm with an incomplete right branch block and negative t waves in v1v3 with no sign of ischemia ( results comparable to previous ecg ) .
the patient was initially managed with intravenous antibiotics ( cephalosporin and metronidazole ) and fluids .
hematological and biochemical investigations revealed an increased white blood cell count ( 10.2  10/l ) and a crp of 434 mg / l , with normal urea , electrolytes , liver function , amylase and bilirubin . based on the deteriorating laboratory values , we planned a surgical cholecystectomy . despite the absence of chest pain
ecg showed st segment depression in v3 in addition to the already known negative t waves in v1v3 . in view of these unexpected ecg findings
the patient was initially managed conservatively using the acute coronary syndrome protocol for anticoagulation with high - dose low - molecular - weight heparin , aspirin and -blockers in addition to the already administered angiotensin - converting enzyme inhibitors .
g / l after 12 h and to 0.30 g / l after another 8 h. cardiac ultrasound showed a mildly enlarged right ventricle , no enlargement of the left ventricle , a good ejection fraction and a right overload septal motion abnormality with pulmonary hypertension ( systolic peripheral arterial pressure 4550 mm hg ) .
an angio - ct was performed to exclude pulmonary embolism ; the findings were negative .
coronary angiography was then undertaken , showing no abnormality and normal left ventricular function . finally , abdominal ct confirmed cholecystitis and excluded empyema or abscess complications ( fig .
the clinical course was favorable , with a progressive disappearance of abdominal symptoms and a return to normal complete blood count , lipase , cardiac markers , electrolytes , bilirubin aminotransferase and crp levels .
in previous studies , gallbladder distension has been associated with nonspecific t - wave inversions or st segment depressions that are similar to those of ischemic heart disease [ 1 , 2 , 3 , 4 ] , and only five previous cases with similar ischemic ecg changes attributed to cholecystitis have been reported [ 5 , 6 , 7 , 8 , 9 ] .
several studies in animals [ 10 , 11 ] have demonstrated that gallbladder distension can reduce coronary blood flow and increase heart rate and arterial blood pressure , and may explain the association with transiently mimicked myocardial ischemia and st segment ecg changes .
increases in troponin are most commonly related to ischemic myocardial cell injury / necrosis , but nonischemic cardiac causes include prolonged tachycardia and septicemia / septic shock [ 12 , 13 ] .
only two previous reports [ 14 , 15 ] have described increased troponin levels in a patient with acute cholecystitis ; the simultaneous presentation of both pathological findings has not been reported .
the new finding in this case was the observation of ecg changes that mimicked myocardial infarction , with a raised troponin i level that did not seem to be attributable to myocardial ischemia , but was exclusively related to cholecystitis .
this case shows that cholecystitis with gallbladder distension can be the sole cause of pathological ecg changes and an increased troponin i level , which should be considered when evaluating patients with similar presentations .
 cardiac troponins are the most sensitive and specific serum markers of myocardial cell injury , but they can also arise without apparent cardiac injury . 
 besides , acute cholecystitis may be associated with nonspecific st - t wave changes in electrocardiography ( ecg ) . 
 the signs and symptoms of gallbladder and heart disease may overlap , which can make diagnosis difficult . 
 we describe the case of a 75-year - old woman with clinical features suggestive of acute cholecystitis associated with transient st segment elevation and elevated troponin i that , after extensive workup , did not seem to be attributable to myocardial ischemia or any other acute cardiac problem , but were exclusively related to cholecystitis . 
 we show that cholecystitis with gallbladder distension can be the sole cause of pathological ecg changes and an increased troponin i level ; this should be considered when evaluating patients with similar presentations . 
Introduction
Case Report
Discussion