Acute Cholecystitis Masking Right-Sided Heart Failure: A Near-Miss Event

Abstract

<h3>Introduction</h3> Pulmonary hypertension (PAH) may lead to progressive right-ventricular (RV) heart failure with symptoms of hypervolemia such as renal or hepatic congestion. We present a case of a critically ill patient presenting as sepsis from acute cholecystitis, which was later unmasked as RV failure due to uncontrolled PAH. <h3>Case Report</h3> A 67-year-old female with known PAH presented with 4 days of right upper quadrant abdominal pain and emesis. She was tachycardic and hypotensive. CT imaging showed a thick, fluid-filled gallbladder with ascites concerning for acute cholecystitis. Lab testing revealed a lactic acid of 10 and leukocytosis of 11,000. She was managed with IV antibiotics and planned for surgery, until a bedside echocardiogram showed a dilated RV and RA with severe tricuspid regurgitation. A catheterization confirmed severely elevated right heart pressures. She was started on IV treprostinil, milrinone, and diuretics with resolution of lactic acidosis and abdominal pain. <h3>Decision Making</h3> The patient's history of PAH along with evidence of hypervolemia led to suspicion of acute RV failure as the cause of cholecystitis. This led to changes in management by holding IV fluids as would otherwise be indicated in sepsis and prompting an urgent echocardiogram and heart catheterization. The diagnosis was confirmed and she was started on appropriate therapy. <h3>Summary</h3> Understanding complications of PAH and acute RV failure, which can produce symptoms similar to an acute abdominal syndrome, may prompt early appropriate interventions and prevent potentially harmful management.