Abstract
A 91-year-old Chinese man with a 30-year history of diabetes and 5-year history of hypertension presented in January 2026 with acute epigastric pain and obstructive jaundice. Unenhanced CT showed dilated bile ducts with multiple linear hyperattenuating structures mimicking biliary stones. ERCP after sphincterotomy yielded abundant blood clots but no calculi, with persistent active bleeding; cholangioscopy revealed an irregular friable bleeding lesion at the left hepatic duct/hilar confluence. Fully covered metal and plastic stents were placed, with marked reduction of bleeding. Follow-up CT two weeks later showed a 5.5×3.6 cm segment-VI mass with wash-in/wash-out enhancement, consistent with hepatocellular carcinoma. Intraductal blood clots can mimic biliary stones; cholangioscopy localized the bleeding source during ERCP and redirected management.