Gallbladder Heart Syndrome

General Information:

Gallbladder Heart Syndrome, also known as biliary cardiac syndrome or biliary chest syndrome, is a constellation of symptoms characterized by altered cardiac activity due to a disorder in the gallbladder or biliary tract. The condition primarily manifests as chest pain, cardiac arrhythmias, and decreased efficiency of electrical signal transmission in the heart, occurring at the peak of a gallbladder (hepatic) colic episode or exacerbation of cholecystitis. Diagnosis is based on medical examination, echocardiography of the heart and gallbladder, electrocardiography, and blood analysis. Treatment includes dietary adjustments, antispasmodics, and choleretics. Surgical treatment may involve gallbladder removal through laparoscopy or open surgery.

ICD-10 Classification: K81 Cholecystitis

Definition:

Gallbladder Heart Syndrome (biliary cardiac syndrome, biliary heart syndrome, biliary chest syndrome) – a set of metabolic and functional changes in cardiac muscle activity, resulting from a negative impact on the heart muscle due to abnormal processes in the biliary system. The prevalence of the disease ranges from 25-57% in cases of simple chronic cholecystitis and 15% in cases of jaundice. Variability in statistics is attributed to the difficulty of identifying the condition and making a differential diagnosis. Women suffer from this disease three times more than men, with the average age of patients ranging from 35 to 55 years.

Causes:
The disease develops due to pathological processes in the gallbladder and biliary tract:

1. Acute and chronic cholecystitis with or without stones.
2. Stricture of the distal bile ducts due to sphincter inflammation causing narrowing of the ampulla of Vater. Gallbladder syndrome commonly occurs in individuals with a history of ischemic heart disease, cardiac arrhythmias, chronic heart failure, and hypertension. Gallbladder colic or exacerbation of cholecystitis can be triggers for the development of this syndrome.

Pathogenic Mechanisms:

The pathogenic aspects of gallbladder heart syndrome are subject to debate among scientists worldwide. In modern gastroenterology, there are several prevalent and equally plausible theories regarding disease development:

1. Reflex Theory: According to this theory, inflammatory diseases affecting the biliary secretion system abnormally influence the autonomic nervous system (parasympathetic and sympathetic), leading to rhythmic disturbances, coronary artery spasm, and so on.
2. Metabolic Exchange: Due to recurrent exacerbation of cholecystitis and gallstone disease, disturbances in metabolic exchange (electrolytes, carbohydrates, fats, proteins, etc.) occur. These changes in metabolic processes lead to inhibition of metabolic reactions in cardiac muscle.
3. Infection and Intoxication: Bacterial toxins released during exacerbations of hepatobiliary infections (liver, gallbladder, biliary ducts) have a cardiac effect. In the presence of biological imbalance and evident intoxication, there is a deteriorative effect on cardiac muscle due to toxic origins.

Symptoms:

Symptoms typically appear after consuming fatty foods, alcohol, or experiencing high levels of emotional stress. The expression of the syndrome varies. Often, it manifests as sharp, intermittent pain, compressive or piercing, in the heart region, radiating to the lower left side of the chest, shoulder, and jaw. These pains occur during exacerbation of gallbladder inflammation or cholecystitis. Bloody and compressive pain to the left of the chest may be the only symptoms of a gallbladder secretion disorder.

There is a form of the syndrome without pain where disturbances in heart rhythm (atrial fibrillation, palpitations, atrial flutter) are the main presentation. The rhythm disorders in biliary chest syndrome are associated with the onset of a gallbladder attack and often do not respond to antiarrhythmic therapy. The disease is often associated with tachycardia, high blood pressure, and difficulty breathing.

On the biliary side, severe pain is noted in the lower right side of the chest, digestive disturbances, nausea, and vomiting containing bile, with an increase in body temperature. In case of obstruction of the bile duct by stones, jaundice is added to the main symptoms, with yellowing of the skin and mucous membranes.

Complications:

The fluctuations in biliary chest syndrome are associated with complications of the diseases that led to these disorders. An acute attack of heart pain can lead to the development of a heart attack, loss of consciousness, and even death. Various disorders in heart rhythm without treatment in the context of current heart disorders effectively injure the heart, leading to fatal rhythm disturbances (ventricular fibrillation and tachycardia) until reaching asystole.

Spasms of the coronary vessels can lead to the development of acute coronary syndrome, and prolonged oxidative damage to the myocardium can lead to a heart attack. On the biliary secretion side, gallbladder penetration by stones can lead to the development of peritonitis and septicemia. When infection is added, biliary aggregation can occur.

Diagnosis:

The lack of distinctive signs and the blurring in the clinical picture make differential diagnosis difficult. The search for an optimal diagnostic algorithm is of interest to doctors of various specialties (internists, gastroenterologists, surgeons, etc.). A multifaceted examination of the heart, vascular, and biliary systems is assigned:

Specialized examination: Patients often seek specialized doctors (cardiologists, gastroenterologists) depending on the nature of the main symptoms. The specialist collects medical and life history, performs a clinical examination, focusing on the relationship between the onset of heart pain or rhythm disturbances and exacerbation of gallbladder inflammation or biliary colic.

Biliary system diagnosis: To study the biliary system, an ultrasound examination of the gallbladder and bile ducts is performed. In the case of gallstones, endoscopic retrograde cholangiopancreatography (ERCP) is performed to visualize the bile ducts. In controversial or difficult cases, magnetic resonance cholangiopancreatography is used.

Assessment of the heart and vascular system: To exclude heart diseases, an electrocardiogram (ECG) is performed, which can detect rhythm disorders and involvement of the atrioventricular and atrial-ventricular nodes and variable atrial mass. In some cases, 24-hour Holter monitoring is performed using a Holter monitor. Echocardiography provides important support in identifying the source of symptoms and determining their impact on the heart and biliary system.

Blood analysis: During exacerbation of gallbladder inflammation, the number of white blood cells and the level of bilirubin in the blood increase, and the erythrocyte sedimentation rate accelerates. To exclude a heart attack, levels of CK, CK-MB, troponin, LDH, and LDH-1 are determined.

Differential Diagnosis:
Differential diagnosis of biliary chest syndrome is carried out to exclude disorders in the cardiac and vascular systems, such as ischemic angina, other cardiac rhythm disorders, and heart attack. In cases of non-painful patterns with a predominance of neurovascular syndrome, the disease must be distinguished from anxiety and nervous tension disorders.

It is important in the diagnostic process to monitor the onset of heart pain and the extent of its association with complaints from the biliary and biliary systems. Medical imaging techniques such as ultrasound and magnetic resonance imaging provide important support in identifying the source of symptoms and determining their impact on the heart and biliary system.

If the condition is unclear or requires advanced evaluation, referral to different specialists such as internists, surgeons, and diagnostic radiologists may be necessary to provide comprehensive care.

Coordination between cardiologists and gastroenterologists is essential for optimal patient care, especially in cases of biliary chest syndrome, which require a precise understanding of the interaction between the digestive and cardiac systems.

Treatment of Biliary Chest Syndrome:

Treatment strategy depends on the patient’s condition, severity of cardiac symptoms, and type of digestive system disorder. There are two main options for treating this condition:

Conservative: Shown to be effective in cases of cholecystitis without stones with rare exacerbations (once or twice a year), when gallstones are present in the gallbladder not exceeding 10 mm in size and maintaining its function and the opening of the bile duct. Conservative treatment is used in case of severe physical health status until improvement occurs. A strict diet reducing consumption of fatty and fried foods, alcoholic beverages, and sodas is recommended. Medications such as ursodeoxycholic acid affecting stones by gradually dissolving them are prescribed. In the case of small stones, extracorporeal shock wave lithotripsy is performed without surgery.

Surgical: Used when conservative treatment is ineffective, and in cases of large and poorly rotating stones unsuitable for cholecyst

Here are the sources:

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