A Case of Myocardial Infarction Misdiagnosed as Cholecystitis and How to Reduce Missed Diagnosis Rate of Myocardial Infarction

🥼 Practice and Clinical
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A Case of Myocardial Infarction Misdiagnosed as Cholecystitis

Recently, our group admitted a patient with acute myocardial infarction (middle-aged male). Initially, the patient was admitted with right upper abdominal pain and was treated by general surgery for acute cholecystitis. Later, during the night, he developed left chest and back pain. Cardiology was consulted, and the electrocardiogram was abnormal. Emergency tests showed elevated myocardial enzymes. After further inquiry, a history of coronary artery disease was found. The patient was finally transferred to our cardiology department for treatment and further auxiliary examinations, confirming the diagnosis of acute myocardial infarction.

Subsequent analysis of this case led the director to point out the need to differentiate between biliary-cardiac syndrome and acute myocardial infarction. Upon reviewing related literature, it was found that biliary-cardiac syndrome is easily misdiagnosed as myocardial infarction due to the presence of the biliary-cardiac reflex (along with other theories[1]). When the gallbladder is diseased, symptoms similar to myocardial infarction can appear, hence it is often misdiagnosed as myocardial infarction, with a misdiagnosis rate exceeding 50%[2].

However, personally, I believe that treating cholecystitis as myocardial infarction is not a big problem if cholecystitis is not treated promptly. But if myocardial infarction is treated as cholecystitis, delayed treatment of myocardial infarction may be fatal. Unfortunately, I did not find articles about myocardial infarction misdiagnosed as biliary diseases. However, I found some other cases[3], such as myocardial infarction being misdiagnosed as digestive tract diseases or respiratory diseases.
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How to Reduce Missed Diagnosis Rate of Myocardial Infarction

The consequences of missed diagnosis of myocardial infarction are very serious since the critical treatment window is only 12 hours. Combining these cases and the teacher’s explanation, the experience is summarized as follows, hoping to inspire others to add insights.

How to reduce missed diagnosis rate of myocardial infarction (2)

  1. Qin Ling, Wang Libo, Gulanlishu County Hospital of Traditional Chinese Medicine, Department of Internal Medicine. Research progress on the pathogenesis of biliary-cardiac syndrome [J]. Journal of Clinical Hepatobiliary Diseases, 2002(4): 197-198. ↩︎

  2. Yang Shixian, Wu Tieyong, Liu Xiaogang. Analysis of 220 cases of misdiagnosis of biliary-cardiac syndrome [J]. Journal of PLA Medicine, 2015, 27(6): 63-65. ↩︎

  3. Fan Yanqin, Liu Hong, Wang Yuan. Clinical analysis of missed diagnosis and misdiagnosis of coronary heart disease in the elderly [J]. Practical Geriatrics, 2011, 25(3): 236-238+242. ↩︎

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The following content is from Reigo @ Sunday’s Saliya

The diagnosis of any disease is a combination of medical history, symptoms, signs, and auxiliary examinations. Often, asking detailed questions about medical history and onset triggers can provide clear indications.

Cholecystitis, as a surgical acute abdomen, is characterized by a clear trigger, usually caused by eating greasy food, and the patient often has a history of gallstones. In contrast, the essence of myocardial infarction (MI) is an imbalance between oxygen supply and demand. The triggers of acute myocardial infarction (AMI) usually include cold exposure, emotional agitation, and strenuous activity—these behaviors increase myocardial oxygen consumption or cause insufficient coronary blood flow and are less related to eating.

Both conditions have pain symptoms, but classic internal medicine and surgery exam questions highlight the differential diagnosis of acute abdomen: the typical symptom of cholecystitis is cramping pain in the right upper abdomen, with a fixed location (except for anatomical variations), which can radiate to the right scapula. If inflammation involves the serosal layer, pressing the abdominal wall can stimulate the parietal peritoneum, resulting in a positive Murphy’s sign. AMI pain varies; the classic presentation is a squeezing pain behind the sternum (not the precordial area), which can radiate to the left scapula and the inner side of the left upper limb. However, there are many atypical presentations, such as inferior wall infarction presenting as discomfort below the xiphoid or digestive symptoms like belching. At this point, the importance of the ECG and cardiac biomarkers becomes apparent. For emergency patients with pain anywhere from below the eyebrows to above the knees, no matter what, perform an ECG; for high-risk populations, do both an ECG and blood tests simultaneously, as the current diagnostic criteria for MI require cardiac biomarkers as an essential criterion.

Distinguishing between biliary-cardiac syndrome and myocardial infarction is actually quite simple. The patient’s history usually provides a direct clue. Moreover, biliary-cardiac syndrome manifests as bradycardia or even cardiac arrest (a result of vagal nerve stretch). This slow heart rhythm should mainly be sinus rhythm since sinoatrial node function is intact. Some right coronary artery occlusions can also present with bradycardia, but ECG will show atrioventricular block, escape rhythms, and other manifestations because the sinoatrial and atrioventricular nodes are supplied by the right coronary artery, and its occlusion impairs their function.