Transjugular Liver Biopsy and the Bloody Mess That Follows: A Rare Case of Hemobilia and Hemocholecystitis

A 59-year-old woman with newly diagnosed, treatment-naïve hepatitis C presented with right upper quadrant abdominal pain. One day prior, she underwent transjugular liver biopsy to evaluate for cirrhosis. Physical exam revealed stable vital signs, jaundice, scleral icterus, and guarding to right upper quadrant palpation. Liver function tests were consistent, with total bilirubin 11.2 mg/dL, AST 354 U/L, ALT 209 U/L, PT 15.2, and INR 1.2. Hemoglobin was 8.9 g/dL, decreased from baseline of 15 g/dL. Abdominal computed tomography showed a large soft tissue density extending the entire length of the common bile duct (Figure 1). ERCP was performed, finding a dilated CBD greater than 2.5 cm with multiple large, amorphous filling defects (Figure 2). Repeated balloon sweeps revealed blood clots (Figure 3), and a nasobiliary tube was left in place for flushing. Despite this, the patient developed hemorrhagic shock. She underwent angiography, revealing distal hepatic artery laceration and subsequent coil embolization achieved hemostasis. After procedure, hemoglobin and vital signs stabilized. However, on hospital day 12, she again developed severe