Bleeding causing biliary obstruction after endoscopic sphincterotomy

A 68-yr-old woman who had had a cholecystectomy and endoscopic sphincterotomy developed recurrent common bile duct obstruction. She had another ERCP with extension of the site of endoscopic sphincterotomy, and 3 days later biliary obstruction again developed, this time from a blood clot filling the common bile duct. The clot was removed by Fogarty technique, and the duct was irrigated with heparin; the obstruction resolved. Minor hemobilia (biliary tract hemorrhage without overt GI bleeding) may be confused with choledocholithiasis. When biliary obstruction follows endoscopic sphincterotomy, attempts at flushing the duct should precede empiric maneuvers for stone removal.