Cope’s sign (cardio-biliary reflex)

Rapid response call, 02:30 am. A 45 year old female was admitted for syncopal episode after eating high fatty food who suddenly became bradycardic on her third hospital day. She was diagnosed with acute calculous cholecystitis awaiting laparoscopic cholecystectomy. She became bradycardic in the 40’s with a sustained SBP of 77 mmHg. A POCUS was done by one of our code RN and found to be fluid tolerant with an IVC of > 70% collapsibility, normo-dynamic heart, and negative B-lines on all lung fields. Initial interventions were as follow: EKG, confirming sinus bradycardia, 1L LR bolus with very minimal effort on BP. (SBP 82 mmHg). Pt continued to feel slight pain to mid abdomen and back. Serial labs sent for analysis. She reports some nausea and slight dizziness. Post LR infusion, atropine 1 mg was given which improved HR and BP.

Cope’s sign was named by Sir Zachary Cope who was the first patient reported with cardio-biliary reflex. Cardio-biliary reflex is thought to be vagally mediated. More specifically, cardio-biliary reflex has been triggered by pain in the gallbladder via autonomic vagal innervations. Bradyarrhythmia is the most common clinical presentation of the cardio-biliary reflex.

Cardio-biliary reflex can cause severe bradyarrhythmia, even a complete heart block.

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