An 88-year-old woman was admitted for painless obstructive jaundice.
Personal history included deep venous thrombosis, duodenal ulcus with upper gastrointestinal bleeding and ischemic heart disease under treatment.
It begins with a one week history of colic pain in the right hypochondrium, characterized by fever, jaundice, nausea and vomiting.
Abdominal examination revealed pain in the right hypochondrium.
Abdominal ultrasound showed a homogeneous liver with dilatation of intra-extrahepatic bile duct, highly 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.
Pancreatic area with normal ultrasound appearance.
Dual hypoechogenicity and increased volume of pancreatic head.
Wirsung within normal limits and distended gallbladder.
Analytically, he presented: total bilirubin 11 mg/dl; 8.23 mg/dl of direct mg/dl, amylase 1,435 mU/ml and hemoglobin 11 g/l.
Transparietohepatic cholangiography was performed as a diagnostic and therapeutic measure.
Moderate intrahepatic bile duct dilatation with moderate bile duct dilatation secondary to obstruction at the distal portion of the duodenum was observed.
A passage through the obstruction was achieved leaving an internal-external drainage catheter confirming its proper placement and functioning by cholangiography.
During the following days he developed hemobilia with catheter obstruction that was self-limiting, with a fall in hemoglobin levels and without hemodynamic repercussions.
Given the age of the patient and the diagnosis of head of pancreas neoplasia, palliative treatment was chosen with placement of endoprosthesis (biliary wall stent staying from 10 x 70 mm proximal duodenal lumen length).
After its placement, the patient developed episodes of gastrointestinal bleeding with hemodynamic repercussions in subsequent days, which was a transfusion subsidiary.
There was no previous diagnostic method because it seemed difficult to suspect the cause.
Selective arteriography was performed to diagnose active bleeding location.
Selective arteriography of celiac trunk and hepatic artery was performed, visualizing a 1 cm pseudoaneurysm in branch of right hepatic artery.
Selective catheterization was performed to introduce metallic coils that were not technically compatible with tortuosity of the celiac trunk and hepatic artery arising from the catheter.
A new selective splenic and hepatic arteriography was performed, showing patency of the axis isoportal and pseudoaneurysm of the branch of the hepatic artery with intrahepatic closure of the hepatic artery and selective catheterization of the branch.
The evolution was satisfactory with bleeding control, as well as good biliary drainage with normalization of bilirubin levels.
