In this case report, we present a patient with characteristics concordant with the Quincke’s triad . Hemobilia is a rare etiology of UGIB and often missed in the early diagnosis establishment, especially when there is no history of trauma or invasive hepatopancreatobiliary procedure . Historically, trauma has been the most frequent cause of hemobilia, but Green et al.  reported on a change in the etiological profile; specifically, the overall increase in patients undergoing invasive hepatopancreatobiliary procedures had led to an iatrogenic etiology becoming the most common cause of hemobilia, accounting for 65% of cases.
Surgery performed around the biliary tract, such as cholecystectomy, liver transplant, or pancreatoduodenectomy, carries risk of causing concurrent injury to the surrounding blood vessels and biliary tract, which can lead to fistula formation [2, 6]. Furthermore, exposure of bile from a leaking biliary duct into injured blood vessels could impair the healing process and cause pseudoaneurysm .
The patient presented herein had denied any history of abdominal trauma. However, she had a history of LC three years prior to admission. In LC, vascular injury can be caused by the mechanical maneuvers during surgical clip placement or cystic duct resection, by erosion of the blood vessels by the clip itself, or by heat (thermal injury) directly from the cauterization or indirectly transferred by the clip [8, 9].
In general, hemobilia occurs within 4 weeks after trauma or invasive procedure, while hemobilia caused by endoscopic retrograde cholangiopancreatography or percutaneous biliary drainage usually occurs immediately or within days . Hemobilia due to pseudoaneurysm rupture may occur several years after the invasive procedure , but such cases are rare. The delayed onset could be due to a slowly progressing pseudoaneurysm but could result in a massive bleeding event [10, 11].
Tessier et al.  reported a mean time of 5.7 months between initial invasive intervention and diagnosis of hepatic artery pseudoaneurysm, with the longest interval being 38 months after the procedure. There are two case reports in the literature of delayed-onset hemobilia that occurred after more than 1 year. The first, by Badillo et al. , reported on a hemobilia case that occurred 15 months after LC. The second, by Kumar et al. , reported on a hemobilia case that, similar to our case, occurred 3 years after LC.
Hemobilia should be suspected in UGIB with an unknown source, especially if there is a history of abdominal trauma or hepatopancreatobiliary procedure [2, 4]. Any signs and symptoms of biliary obstruction, both on clinical and laboratory examinations, in UGIB patients with unknown cause should be suspected as hemobilia [4, 6].
Symptoms of hemobilia depend on the source and amount of bleeding, which could be hematemesis, melena, hematochezia, or a combination of these [10, 11]. Postpercutaneous invasive procedure hemobilia is characterized by bleeding from the drainage catheter . Massive hemobilia, such as in our case, may show symptoms of hematochezia, but this complicates diagnosis, risking the misdiagnosis of lower gastrointestinal bleeding .
EGD is a common early method applied in the diagnosis of patients with UGIB, especially when there is no suspicion of hemobilia [3, 7]. Blood flowing from or a blood clot at the ampulla of Vater, as detected by EGD, confirms the diagnosis of hemobilia. Furthermore, EGD is also useful for ruling out other sources of bleeding . The success of EGD in detecting hemobilia depends on the duration and severity of the bleeding . Gandhi et al.  reported that 62% of hemobilia cases that underwent EGD showed bleeding in the second part of the duodenum.
In suspected cases of hemobilia with stable hemodynamics, the diagnostic procedure could be conducted with computed tomography angiography (CTA) without previous EGD . CTA is capable of determining the location of bleeding but unable to determine severity of the bleeding [1, 2]. CTA in patients with hemobilia will show contrast extravasation, blood clot in the biliary system, or vascular malformation [11, 14]. The key advantages of CTA are its noninvasive nature, lower radiation exposure, and provision of a rapid result. The subsequent hepatobiliary vascularization reconstruction can also guide the selection of embolization location, especially in patients with anatomical transformations, for example the post-liver transplant patient [7, 10].
Angiography has become the first choice for diagnosis of hemobilia, and radiological intervention is the preferred treatment modality, especially for patients with unstable hemodynamics [2, 13]. Angiographic technology allows for visualization of the vascular anatomy and localization of bleeding, as marked by contrast extravasation to the biliary system in hemobilia. Moreover, it may also show any arteriobiliary fistula or vascular malformation (aneurysm, pseudoaneurysm, or hemangioma) [15, 16]. One study determined that angiography is remarkably superior to CTA for detecting pseudoaneurysm (100% versus 67%) .
The hepatic artery is the most common location of post-LC pseudoaneurysm, followed by the cystic artery [11, 13, 14]. Cases of gastroduodenal artery pseudoaneurysm are rare, accounting for only 1.5% of all reported cases of visceral artery aneurysm; however, the majority of gastroduodenal artery pseudoaneurysms are caused by pancreatitis . To our knowledge, the case described herein is the fourth reported case of hemobilia due to ruptured gastroduodenal artery pseudoaneurysm after cholecystectomy [18,19,20,21].
Because hemobilia is a rare etiology of UGIB, it should be suspected in UGIB with unknown source, especially in patients with a history of abdominal trauma or hepatopancreatobiliary procedure, regardless of the time interval between the procedure and the onset of bleeding.