# Three Cases of Biliary Disease Presenting With Chest Pain: Diagnostic Pitfalls and the Impact of Cognitive Biases in Noncardiac Chest Pain

## TL;DR

Three cases show how biliary disease can mimic heart-related chest pain, causing delays in diagnosis and highlighting the need for careful evaluation and awareness of cognitive biases.

## Contribution

The paper presents three clinical cases emphasizing the diagnostic challenges of biliary disease mimicking cardiac chest pain and the role of cognitive biases.

## Key findings

- Biliary disease can present with chest pain similar to acute coronary syndrome, leading to diagnostic delays.
- Elevated liver enzymes and positive Murphy’s sign can help identify biliary disease after ruling out cardiac causes.
- Cognitive biases like anchoring and availability can hinder accurate diagnosis in emergency settings.

## Abstract

Chest pain is a frequent chief complaint among patients visiting the emergency department, and those with acute coronary syndrome (ACS) are usually prioritized during initial evaluation. However, biliary diseases occasionally mimic cardiac chest pain, leading to diagnostic delays. We describe three patients who presented with chest or epigastric pain and were initially suspected of having ACS. In each case, cardiac biomarkers and electrocardiograms were nondiagnostic, whereas liver or biliary enzyme abnormalities and imaging studies revealed acute cholecystitis or cholangitis. All patients underwent appropriate surgical or endoscopic intervention and achieved complete recovery. These cases highlight that biliary disease can present as noncardiac chest pain because of shared visceral afferent pathways. Clinicians should systematically reassess for abdominal sources after ACS is excluded, particularly when liver enzyme levels are elevated or Murphy’s sign is positive. Awareness of cognitive biases, including anchoring, availability, and framing, is essential for avoiding diagnostic delays in emergency settings.