PMC6710687_01
Left: duodenal ulcer with adherent clot. Right: endoclip deployment with hemostasis.
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The ulcer was not bleeding but was prophylactically treated with epinephrine around the ulcer and an endoclip deployed on the ulcer (Figure 1).
Hemobilia noted from papilla prior to sphincterotomy.
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Once ERCP was started prior to making a sphincterotomy, there was evidence of heme material being expelled from the ampulla of Vater along with stones (Figure 2).
Blood clots and stones noted after balloon sweeps.
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After sphincterotomy and balloon sweeps of the common bile duct (CBD) were performed, a large amount of blood and clots were removed (Figure 3).
Post-CBD stenting without further evidence of hemobilia.
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A 10 x 80 mm covered metal stent was then placed in the CBD (Figure 4).
CT angiogram showing the right hepatic pseudoaneurysm and biliary stent with no evidence of active extravasation.
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A stat computed tomography (CT) scan with contrast was then obtained to evaluate for the source of bleeding, revealing a pseudoaneurysm adjacent to the gallbladder with a pericystic hematoma (Figure 5).
Left: selective hepatic artery angiogram showing the right hepatic artery pseudoaneurysm. Right: no filling of the pseudoaneurysm after transarterial coil embolization with distal branch filling via collateral flow.
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Superselective catheterization was performed, with coil embolization of the pseudoaneurysm (Figure 6).