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

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.