Often a biliary endoprothesis is used and is left in place for several weeks until fistula closure, while endoscopic sphincterotomy alone, with the intention of reducing the pressure gradient between the biliary system and duodenum, is indicated only in specific circumstances (distal biliary strictures) [9]. Operation is indicated when non operative

measures are not suitable, such as in patients with diffuse bile peritonitis, in septic patients. The increased use of interventional procedures in the management of biliary disorders is associated with an increased incidence of buy JSH-23 vascular injuries [10]. Hemobilia is an uncommon cause of gastrointestinal bleeding. Trauma has become the most common cause of NCT-501 hemobilia since the advent of invasive procedures such as percutaneous liver biopsy, transhepatic cholangiography, and biliary drainage; it may also be caused by infection and arteritis associated with cholecystitis or pancreatitis and shows strong associations with disease processes such as atherosclerosis, cystic medial necrosis and polyarteritis nodosa [11] but in the case reported it has been check details due to the presence of pseudoaneurysm of the hepatic artery. Pseudoaneurysm accounts for nearly 10% of hemobilia cases [12], which have been associated with percutaneously placed devices [13]. Before hemobilia, we diagnosed 3 episodes of cholangitis and elevated levels of bilirubin,

suggesting an increased intraductal pressure, which may have caused this vascular injury. Chronic inflammation suggests that there might be some degree of continuing low-grade damage within the liver parenchyma. As the inflammation proceeds and involves the collateral hepatic artery, a pseudoaneurysm this website forms and raises the risk of hemobilia. It therefore seems likely that PTHBD induced aneurismal change of the hepatic artery in combination with increased ductal pressure and cholangitis. We belive that the inflammation surrounding the bile ducts and the presence of adhesions between the PTHBD and the right branch of hepatic artery may have contributed to the formation of pseudoaneurysm because the tip of the PTHBD was at the same site

of vascular injurie. Then the fistulous communication between biliary tree and vascular structures has lead hemobilia, which can be severe and life-threatening. In fact in our case reported, the patient underwent to 4 blood transfusions because of an acute anaemia and shock. Quinkle’s triad, composed by epigastric pain, hemobilia and obstructive jundice, is the classical clinical presentation of an intrahepatic artery pseudoaneurysm. These occur in 73%, 52%, and 30% of cases, respectively, although the complete triad occurred in only 22% of the them[1]. Blood may rapidly flow into the duodenum, simulating an intestinal bleeding or may lead, if the flow is slow, the formation of blood clots, obstructing the bile ducts and causing jaundice.