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A 69‐year‐old man underwent endoscopic retrograde cholangiopancreatography for the evaluation of suspected hilar cholangiocarcinoma in the presence of primary sclerosing cholangitis. Cholangiography confirmed a hilar tight stricture. A 0.035‐inch soft‐tipped hydrophilic guidewire was advanced into the right intrahepatic biliary system. Balloon dilation, right intrahepatic biliary brush cytology and common hepatic intraductal biopsies were performed. Initially, a 7‐French, 15 cm stent was placed in the right intrahepatic system, but was subsequently replaced with a shorter 12 cm stent. A stent was also placed into the left system.
Over the next 48 h, the patient developed severe stabbing upper abdominal pain, aggravated by inspiration and right shoulder pain. Serum haemoglobin dropped from a baseline of 15 to 11.5 g/dl. Of importance, platelet count (236×103 /μl) and coagulation parameters (prothrombin time 10.2 s and international normalised ratio 1.0) were normal. He denied fever, chills, melaena or bright red blood per rectum. An abdominal CT scan was performed (fig 11).
What is the diagnosis?
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Competing interests: None.