Incidental hemobilia diagnosed during emergency ERCP for acute cholangitis in a patient on antiplatelet therapy

Antiplatelet therapy is a well-established risk factor for gastrointestinal bleeding, yet hemobilia induced by these agents remains rarely reported. Acute cholangitis secondary to choledocholithiasis in patients on antiplatelet therapy presents significant clinical challenges, as the medication can precipitate hemobilia, subsequently exacerbating the cholangitis. Here, we report a 73-year-old female with a history of multiple biliary interventions and long-term aspirin use, exemplifying this clinical challenge. Although elective endoscopic retrograde cholangiopancreatography (ERCP) was scheduled following a 1-week aspirin discontinuation, the sudden onset of severe abdominal pain necessitated emergency intervention. ERCP revealed hemobilia with clots obstructing the major duodenal papilla. Therapeutic ERCP successfully evacuated the clots, extracted the stones, and placed a nasobiliary drain. The patient stabilized without requiring angiography or surgery. This case highlights that abrupt changes in abdominal pain patterns in calculous cholangitis patients receiving antiplatelet therapy should raise suspicion for hemobilia, underscoring the need for timely and effective clinical intervention.