Cope's sign: A lesson for novice physicians

We report a case of a 28-year-old male who presented in the emergency room with a history of two episodes of syncope in the last 3 days at home. ECG was done in the emergency room which was suggestive of complete heart block. The patient had a history of pain on and off in the right upper quadrant region (RUQ) after having a meal. Ultrasonography of the abdomen was advised which revealed acute calculous cholecystitis. A temporary pacemaker was inserted and an emergency laparoscopic cholecystectomy was planned. The patient recovered postoperatively and converted back to sinus rhythm. Considering the patient's age, normal cardiac workup, and his complete heart block disappeared after the removal of his gallbladder, it was postulated that this patient had a case of cardio-biliary reflex (Cope's sign).