When the Gallbladder Follows The Right Heart: A case report of cardio-biliary syndrome in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a progressive condition that may lead to chronic right heart failure and systemic venous congestion. One of the lesser-known consequences of this hemodynamic overload is passive hepatic congestion and impaired bile clearance. In rare instances, this pathophysiological process extends to the gallbladder, promoting the formation of sludge and symptoms in the right upper quadrant that may mimic those of primary biliary disease. We report the case of a 42-year-old woman with idiopathic PAH complicated by right heart failure, who presented with persistent abdominal discomfort and vomiting. Imaging revealed congestive hepatopathy and gallbladder sludge without any signs of inflammation or acute cholecystitis. The clinical and imaging findings pointed to a cardio-biliary mechanism. An elective cholecystectomy was performed in the absence of inflammatory signs, leading to complete symptom resolution. This case underlines the importance of recognizing PAH-related hepatobiliary complications and differentiating them from primary biliary pathology, as it significantly impacts management and may prevent unnecessary surgery.