Post-biopsy haemobilia with coagulopathy and a contrast-limited kidney

This is likely haemobilia with active arterial bleeding. Resuscitate first: secure large-bore access, cross-match, start blood products and activate the haemorrhage protocol. Do not delay definitive haemostasis for full laboratory correction, but correct in parallel: transfuse to a haemoglobin that supports oxygen delivery (usually >7–8 g/dL), give platelets if <50 × 10^9/L and vitamin K/PCC if INR is elevated and bleeding is ongoing; check fibrinogen and calcium. Hold aspirin and involve haematology.

Transarterial angiography is first-line because the bleeding is arterial and surgically inaccessible; surgery is reserved for failure of embolisation or haemodynamic instability despite resuscitation. Repeat CT angiography is reasonable only if it will not delay angiography. For the kidney, use low-volume iso-osmolar contrast, hydrate if haemodynamically appropriate, avoid nephrotoxins and document a contrast-enhanced consent. The decision is not ‘correct everything then act’ - it is resuscitate and embolise concurrently.

Cannulate the coeliac axis and obtain a common hepatic angiogram, then use a microcatheter to superselect the segment VI branch. Cone-beam CT helps confirm the bleeding branch and its relationship to the pseudoaneurysm. Embolise as distally as possible, ideally with coils placed distal and proximal to the pseudoaneurysm (‘sandwich’ technique) to prevent retrograde filling. Coils are preferred here because particles can cause biliary ischaemia and glue carries a risk of non-target embolisation in a tortuous hepatic circulation. Avoid embolising the main right hepatic artery or the common hepatic artery unless absolutely necessary. If the branch is too small for coils, gelatin sponge slurry may be used with caution, but not as first choice. Preserve the cystic artery if possible; if the bleeding source is the cystic artery, embolise it selectively. Post-embolisation angiogram must show stasis and no residual blush.

First repeat selective injections and review the earlier CT for a segmental target; use cone-beam CT if available. Consider provocative angiography with a vasodilator such as nitroglycerin or papaverine to unmask a small bleeding point; avoid thrombolytics in an actively bleeding patient. If the CT blush localises to segment VI, empirical embolisation of the corresponding segmental branch is reasonable even if angiography is negative, because the risk of continued haemorrhage outweighs a small, targeted infarct. Do not blindly embolise the main hepatic artery. If the patient is stable and the bleeding has stopped, intensive monitoring and a low threshold for repeat angiography is acceptable. If bleeding recurs or the patient remains unstable, proceed to empirical segmental embolisation or consider surgery in a hepatobiliary centre.