Abstract 329: Cholecystalgia: an Atypical Presenting Symptom of Congestive Heart Failure

Abstract

Acute acalculous cholecystitis is defined as acute inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction. Imaging studies typically show a distended acalculous gallbladder with thickened walls. Heart failure is well known to cause congestive hepatopathy and can be associated with isolated gallbladder edema which is often difficult to differentiate from acalculous cholecystitis. We present a case of cholecystalgia secondary to isolated gallbladder edema without hepatic congestion in a patient with non-ischemic cardiomyopathy mimicking the presentation of acalculous cholecystitis. A 46-year-old female with a past medical history of recently diagnosed non-ischemic cardiomyopathy during a prior hospitalization. Echocardiogram showed biventricular heart failure with EF of 15 to 20% with severe left and right ventricular dilatation and global hypokinesis. Left heart catherization showed no angiographic evidence of coronary artery disease and right heart catheterization demonstrated pulmonary hypertension secondary to left heart disease. She left against medical advice and was non-compliant with her medications. Approximately one month later, she presented with shortness of breath and orthopnea. On physical examination, jugular venous distention, S3 gallop, diffuse crackles and anasarca were noted. Labs showed BNP of 12,735. Chest CT revealed cardiomegaly and diffuse interstitial edema with bilateral pleural effusions and no signs of pulmonary embolus. Metoprolol and bumetanide were initiated for management of her acutely decompensated congestive heart failure. Several days after admission, she developed severe sharp RUQ pain associated with nausea and vomiting. She was tachypneic, diaphoretic with severe tenderness in the RUQ. Abdominal ultrasound revealed no signs of congestive hepatopathy but revealed a diffuse, edematous thickening of the gallbladder wall without evidence of stones. Hepatobiliary scintigraphy revealed preserved gallbladder function with an EF of 88%. The remainder of her care was focused on optimization of the patient’s congestive heart failure with complete resolution of her symptoms. Acute decompensation of congestive heart failure can result in an increase in pulmonary or systemic venous pressure, which may result in vascular congestion. The vascular distention can lead to isolated distention of the gallbladder wall that can mimic symptoms of acalculous cholecystitis. In such patient’s cholecystectomy or percutaneous cholecystostomy is not warranted. Radiographic evidence and symptoms usually resolve with optimization of congestive heart failure treatment. This case details the under-recognized presentation of secondary cholecystalgia in a patient with acute RUQ pain and underlying congestive heart failure.