Acute cholecystitis in a gastric bypass patient complicated by Takotsubo cardiomyopathy

Author(s):
Hugo Bonatti

Background:

Gallbladder disease is a common condition after gastric bypass surgery. Even after weight loss many bariatric patients continue to suffer from comorbid conditions. Takotsubo cardiomyopathy is a rare condition that mimics acute cardiac ischemia but seems to be caused by a catecholamine storm triggered by intense stress.

Hypothesis:

Takotsubo cardiomyopathy may complicate acute cholecystitis.

Methods:

We present a case of acute cholecystitis complicated by a rare condition.

Results:

A 62 year old female presented with acute right upper quadrant (RUQ) pain to the ER. She had a history of laparoscopic gastric bypass 5 years ago and had been non compliant for 2 years missing follow up appointments, gaining weight which caused poorly controlled DM and she did not take her vitamin supplements. Her WBC was elevated, her LFTs were normal and imaging showed acute calculous cholecystitis. She was admitted and started on antibiotics with plans for laparoscopic cholecystectomy. The next day she developed acute chest pain and troponins were elevated with ST changes on EKG. Echocardiography showed a ballooned left ventricle indicative for Takotsubo cardiomyopathy. Symptomatic treatment including antibiotics, betablocker and thiamin infusion was initiated. At three months follow up, ejection fraction had improved from <20% to >50%. The patient underwent interval laparoscopic cholecystectomy, which was technically very challenging due to severe ongoing acute and chronic cholecystitis. There were no cardiac issues but the patient developed an abscess in the gallbladder fossa, which was successfully treated with oral antibiotics.

Conclusions:

Takotsubo cardiomyopathy complicating acute cholecystitis has thus far not been reported. Our patient had a history of gastric bypass and was non compliant with vitamin supplementation. B-1 (thiamine) deficiency may have contributed to the cardiac condition (wet beriberi).