Cope's Sign: A Pacemaker Averted By Palpation!

Figure A is the admission 12-lead electrocardiogram (ECG) of an elderly patient with severe right upper quadrant pain due to acute cholecystitis. It demonstrates sinus bradycardia at a heart rate (HR) of 37 beats per minute (BPM), with P – P variability (green arrows) suggestive of sinoatrial exit block and a premature atrial beat (brown arrow). Figures B and C are axial and coronal plane computed tomography (CT) images of the abdomen, revealing a distended, thick-walled gallbladder with pericholecystic fluid and no cholelithiasis (red arrows). Figure D is a right upper quadrant ultrasound confirming these findings (red arrow) which was consistent with acute cholecystitis. The HR recovered to 75 BPM with pain control and antibiotics (Figure E, blue arrows), with intermittent profound bradycardia and prolonged sinus pauses with junctional escape beat (purple arrow) due to intermittent bouts of pain elicited by palpation and gentle pressure over the right upper quadrant, recovering promptly on release of the pressure, a bedside demonstration of the cardio-biliary reflex (Cope’s sign).