An 89-year-old man presented with recurrent upper abdominal pain, jaundice, rigors, and vomiting. His medical history included type 2 diabetes mellitus, myocardial infarction, and an abdominal aortic aneurysm that had been under regular ultrasonographic surveillance. On examination, a nontender pulsatile mass was palpable midabdomen. Laboratory investigations on admission disclosed the following results: bilirubin, 3.4 mg/dL; alkaline phosphatase, 735 U/L; alanine transaminase, 120 U/L; amylase, 127 U/L; C-reactive protein, 77 mg/L; white blood cell count, 10 400/μL; and hemoglobin, 11.1 g/dL. (To convert bilirubin to micromoles per liter, multiply by 17.104; alkaline phosphatase, alanine transaminase, and amylase to microkatals per liter, multiply by 0.0167; C-reactive protein to nanomoles per liter, multiply by 9.524; white blood cell count to cells ×109 per liter, multiply by 0.001; and hemoglobin to grams per liter, multiply by 10.) Abdominal ultrasonographic and computed tomographic scans showed multiple stones within a dilated common bile duct and an uncomplicated 9-cm infrarenal abdominal aortic aneurysm. Endoscopic retrograde cholangiopancreatography (ERCP) confirmed the presence of 2 large stones that had impacted at the distal end of the common bile duct. A periampullary duodenal diverticulum was also noted. Sphincterotomy was performed, and, because stone extraction was infeasible, a 5-cm 7F pigtail plastic biliary stent was inserted. However, his jaundice and cholangitis failed to improve during the ensuing week, and another ERCP was performed, revealing no evidence of a stent in situ. A 15-cm 10F straight plastic stent was inserted into the common bile duct, with initial clinical improvement. A week later, however, the patient developed severe acute abdominal pain accompanied by peripheral neutrophilia (16 680/μL [to convert neutrophil count to cells ×109/L, multiply by 0.001]). An urgent computed tomographic scan was obtained, preceded by an anteroposterior scout radiograph (Figure 1).