A 64-year-old male patient with a past medical history of pancreatitis, alcohol use disorder, glaucoma, and prior gastrointestinal bleed, presented to the emergency department (ED) complaining of two weeks of abdominal pain, nausea, and vomiting. He reported that he had chronic abdominal pain that had worsened in the prior two weeks. He was hospitalized at an outside facility one month prior for a gastrointestinal bleed, but a source of bleeding was never identified. His surgical history was significant for coil embolization of an inferior pancreaticoduodenal artery (IPDA) pseudoaneurysm sac, measuring 2.2 centimeters (cm) at the time of embolization, with additional coiling of the gastroduodenal artery (GDA) to prevent collateral filling of the pseudoaneurysm. He had also undergone total knee replacement. On arrival, his vital signs were temperature 36.8° Celsius (C) (oral), heart rate 85 beats per minute, respiratory rate 16 breaths per minute, blood pressure 139/67 millimeters of mercury, and oxygen saturation 99% on room air. His physical exam was notable for scleral icterus and moderate abdominal tenderness, worse over the epigastrium, but without rebound tenderness or guarding. Intravenous (IV) access was established, labs were drawn, and the patient was given one liter lactated Ringer’s, 4 milligrams (mg) IV morphine, and 4 mg IV ondansetron. The patient’s laboratory studies were significant for an initial white blood cell count (WBC) of 14.0 per microliter (109/liter) (reference range 4.5–11.0 × 109/liter), hemoglobin 8.6 grams per deciliter (g/dL) (14–18 g/dL), hematocrit 26.6% (41–50%), and platelets of 486 × 109/liter (150–400 × 109/liter). Lipase was elevated at 225 units per liter (U/L) (0–160 U/L). Liver function tests were also obtained and were concerning for total bilirubin 6.0 mg/dL (0.1–1.2 mg/dL), aspartate transaminase 102 U/L (8–33 U/L), and alanine transaminase 127 U/L (7–56 U/L). The patient had evidence of coagulopathy with prothrombin time of 21 seconds (10–13 seconds) and international normalized ratio 1.86 (reference range less than 1.1), despite lack of any systemic anticoagulation. Initial computed tomography (CT) with IV contrast of the abdomen and pelvis revealed a 6.6-cm enhancing lesion in the region of the pancreatic head and common bile duct, consistent with a large visceral pseudoaneurysm without arterial extravasation ( and ). Coils from the prior embolization were present within the pseudoaneurysm sac, indicating that this was a recurrence with significant enlargement of the previously treated pseudoaneurysm. Severe intrahepatic biliary ductal dilation and diffuse dilation of the gallbladder was also seen, with the presumed GDA pseudoaneurysm causing mass effect on the common bile duct (). The imaging results were discussed immediately with IR, and the patient was prepped for emergent embolization. Additionally, IR planned urgent percutaneous biliary catheter placement given concern for cholangitis in the setting of an elevated WBC count and obstructive cholangiopathy. Angiography demonstrated a large IPDA pseudoaneurysm arising from the branches of the superior mesenteric artery. Coil embolization of the arterial inflow and outflow was successful with no persistent filling of the pseudoaneurysm post embolization, with associated preservation of the surrounding jejunal arteries via collaterals. Given that the patient was also found to have biliary ductal dilation with obstruction and concern for cholangitis, a left-sided biliary drain was placed for decompression. The patient tolerated the initial procedure and was admitted to the surgical intensive care unit for ongoing monitoring. Over the following four days, he had improvement of his liver function tests and leukocytosis and was subsequently discharged home. Five weeks after discharge, the patient had repeat imaging of the abdomen and pelvis, which did not show any patent pseudoaneurysm present. He subsequently underwent biliary stent placement with gastroenterology and removal of his biliary catheter.