Cholecystocardial Syndrome (Botkin Syndrome)

Cholecystocardial Syndrome (Botkin Syndrome)

By:Dr.Zharif

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this is the complex of clinical symptoms, which is manifested by pains in the region of heart (cardialgia), by metabolic disorders in the myocardium with disturbance of rhythm and conductivity, shortness of breath, sometimes by worsening in the coronary blood circulation as a result of the reflector and infectious-toxic actions on the myocardium, which are appeared as a result of the defeat by the pathologic process of gall bladder.

acalculous cholecystitis-35%,

the patients of elderly age - 70%.

Clinical “masks” are diverse in their manifestation, which can lead doctor into error.

Are separated cardial, allergic, thyrotoxic, neurotic, rheumatic, solar, gastrointestinal and other “masks”. One of the sufficiently frequently meeting “masks” is cardial.

History

Botkin, who first noted the possibility of reflector be ill in the heart with the gall bladder disease in clinical lectures (1883), since itself from the 25- summer age suffered the gall bladder disease, which flowed with the frequent assaults of colic, and it connected stenocarditic pains in the region of heart with the disease of gall bladder.

You will not hear complaints of the disorder of digestion, pain, inflation of stomach, patient will complain predominantly about the assaults be ill in the side of the hearts, which go with explicit changes in his function, by arrhythmia, by the difficulty of respiration, in a word, with the clear picture of stenocardia.

This attacks continues 8-10 hours, instead of 1/2 hours or several minutes, suddenly it turns yellow after such several assaults of patient.

But investigate it attentively from the very beginning, and you will ascertain that the liver is increased, the gall bladder diseases There is and so that the disorder of heart it is not accompanied by pains, but only by arrhythmia and by the strong difficulty of respiration or by the phenomena of so-called asthma, which reaches sometimes the strong degree.

Etiology

cholecystocardial syndrome can be developed with the following diseases of the bile-secreting ways:

• chronic acalculous cholecystitis;

• acute and chronic calculous cholecystitis

(maximally it is manifested during the bilious colic);

• choleduchlithiasis without the development of bilious hypertension, with bilious hypertension (with the development of mechanical jaundice);

• the pathologic processes, which lead to the contraction of the terminal division of common bilious duct (stenosing papillitis, the tumor of the large papilla of duodenum, infiltrative pancreatitis).

Pathogenesis

The pathogenesis of cholecystocardial syndrome has several mechanisms of the realization: reflector influences on the coronary vessels, the shifts of the metabolism of myocardium (especially at the moment of bilious colic) and the infectious-toxic action on the cardiovascular system with the sharp inflammatory process in the bile-secreting ways.

1. Reflector influence. The afferent pathologic pulsation, which emanate

s from extra and intramural nervous interlacements of the bile-secreting ducts with the spas

m of the sphincters Of

lyutkensa,Mirizzi,Oddi and the expansion of bilious ducts with biliar hypertension, can by means of the sympathetic and parasympathetic nerve fibers influence heart, causing the spasm of coronary vessels, the disturbance of rhythm and the like

2. Change in the metabolism of heart muscle. With the prolonged course of the gall stones disease with the frequent attacks of the biliar colic, complicated by chronic recurrent cholecystitis and associated disturbances of the functions of the liver and the pancreas, is developed the dystrophia of myocardium, connected with the complex disorders of electrolytic, enzyme and carbohydrate balance, which can lead to the disturbances of cardiovascular system.

3. Infectious-toxic action on the heart muscle with the sharp inflammatory process in the bile-secreting system (acute cholecystitis, purulent cholangitis to mechanical jaundice) with the disturbances in the system of homeostasis and the development of the acute dystrophia of myocardium, which is the reason for the increased excitability, disturbances of conductivity and contracting ability of myocardium. Besides the direct mechanisms of the forming of cholecystocardial syndrome, it is necessary to consider that with the age the frequency of morbidity increases by the ischemic disease of heart, by stenocardia and by the disturbances of rhythm, which makes especially unfavorable the flow of cholecystocardial syndrome.

Clinical pictures

pain in the region of heart (cardialgia or reflector stenocardia). .

The cardialgesic and stenocarditic forms of cholecystocardial syndrome are most common with the gall bladder disease (79% of patients).

Character pain

sharp pain 85% of patients

compressing pain 56-65% of patients

splitting pain13-58% of patients

Irradiation of pain from the right subcostal area into the leftist and into the region of the heart (more frequent during the combination of cholecystitis and pancreatitis);

Is possible the analgesic form of the cholecystocardial syndrome, when its only manifestation - disturbance of the rhythm of heart.

Arrhythmias of heart are also different:

ectopic rhythms (0,47%)

extrasystole (9,6-13,9%)

fibrillation arrhythmia (3,5-13,5%),

atrioventricular blockade and/or blockade of the right branch of His's bundle

Differential diagnostics

Between Cholecystocardial syndrome and IHD

Cholecystocardial syndrome is manifested by pains in the region of the hearts (cardialgias), whose appearance is connected with the viscero- visceral reflex on the vagus. First pains appear in by right subcostal area, then in the region of heart. Frequently the pain is localized in the region of the top of heart, and patient indicates its localization sufficiently accurately (by one finger).The pains prolonged, sharp pain, can be paroxysmal pain and be accompanied by dyspeptic phenomena.

harp paincardial Cholecystocardial syndrome important to consider connection be pain with the consumption of food, but one should remember that the pain can arise after physical load. Sometimes accompanied by jaundice.

Cholecystocardial syndrome is characteristic the syndrome of vegetative disfunction with the predominance of parasympathetic tone, neurotic syndrome is the practically integral part of the clinic of the pathology of the bile-secreting ways.

The combination of cardial complaints with the asthenoneurotic phenomena, the lability of pulse and arterial pressure can lead to the formulation of the erroneous diagnosis of vegetovascular dystonia.

During the attack in the blood are noted leukocytosis, neutrophilia, accelerated ESR, bilirubinemia, hyperglycemia, increase in the level of amylase.

On the ultrasound usually are well visible the large and small concrements of gall bladder, the diffuse or local thickening of the wall of the gall bladder (more than 4 mm) and an increase in its echodensity

The shadows of concrements are visible with the presence of the mixed or lime stones in the survey X-ray photograph. With cholecystography and cholegraphy cholesterol and pigment stones give enlightenments or defects of filling, frequently the shadow of gall bladder is absent.

On ECG during the attack of pain are noted negative waves R in the right breast and in lead 3 standard removal. They frequently take place of the disturbance of rhythm (extrasystole, atrioventricular blockade I st.), diffuse changes in the myocardium are noted.

Treatment

Cholecystoectomy

Ref:translated and edited from Russian Cardiology Website