88-year-old woman admitted for painless obstructive jaundice. Her personal history included deep vein thrombosis, duodenal ulcer with upper gastrointestinal bleeding and ischaemic heart disease under treatment.
She began with colicky pain in the right hypochondrium for a week, associated with fever, jaundice (choluria and acholia), nausea and vomiting. On examination, the patient had a painful abdomen in the right hypochondrium.
Abdominal ultrasound revealed a homogeneous liver with dilatation of the intra-extrahepatic bile duct, a very dilated common bile duct, 22 mm to its most distal portion at its mouth in the papilla. No lithiasis or possible obstructive cause was observed. The pancreatic area had a normal ultrasound appearance. Doubtful hypoechogenicity and increased volume of the pancreatic head. Wirsung at the limit of normality and distended gallbladder.
Laboratory tests showed: total bilirubin 11 mg/dl; 8.23 mg/dl of direct mg/dl, amylase 1,435 mU/ml and haemoglobin 11 g/l.
Transparihepatic cholangiography was performed as a diagnostic and therapeutic measure. This showed moderate dilatation of the intrahepatic bile duct with moderate dilatation of the common bile duct secondary to obstruction at the level of the distal portion of the duodenum. Passage through the obstruction was achieved and an internal-external drainage catheter was left in place, and its proper placement and functioning was confirmed by cholangiography.
During the following days she developed haemobilia with catheter obstruction that self-limited, with a fall in haemoglobin levels and no haemodynamic repercussions.
Given the age of the patient and the diagnosis of pancreatic head neoplasia, palliative treatment was chosen with placement of a stent (biliary wall stent 10 x 70 mm in length) which was lodged from the proximal common bile duct to the interior of the duodenal lumen. After placement of the stent, she developed episodes of gastrointestinal bleeding with haemodynamic repercussions in the following days, requiring transfusion. There was no previous diagnostic method because it seemed difficult to suspect the cause.
Selective arteriography was chosen to diagnose the location of the active bleeding. Selective arteriography of the celiac trunk and hepatic artery was performed, and a 1 cm pseudoaneurysm was visualised in the right hepatic artery branch. Selective catheterisation was attempted to introduce a metallic coil, which was technically unsuccessful due to tortuosity of the celiac trunk and hepatic artery that expelled the catheter.
A new selective splenic and hepatic arteriography was performed, visualising permeability of the splenoportal axis and pseudoaneurysm of the intrahepatic branch of the hepatic artery, achieving selective catheterisation of the branch with pseudoaneurysm and introduction of a metallic coil 3-5 mm in diameter, achieving closure of the bleeding vessel. The evolution was satisfactory with control of the bleeding, as well as good drainage of the biliary tract with normalisation of bilirubin levels.

