LAUSR

Intraductal papillary neoplasms of the bile duct (IPN-B) are rare. These tumors can obstruct bile flow either by luminal occlusion or by secretion of excessive mucin (mucinous subtype). No standard guidelines on management or surveillance of IPN-B exist. Surgical resection remains the definitive treatment of IPN-B. The radiologic appearance of IPN-B, mimicking cholangiocarcinoma, can pose a significant diagnostic dilemma. Direct visualization with cholangioscopy may clarify the diagnosis and facilitate targeted biopsy. A 75-year-old man presented with abdominal pain and progressive cholestatic jaundice. He had a history of laparoscopic cholecystectomy for adenocarcinoma of the gallbladder (pT1, pN0, R0) in 2010. He underwent MRCP (Fig. 1), which demonstrated dilated intrahepatic ducts in both right and left lobes of the liver with multiple intraluminal filling defects, believed to be potentially arising from the duct walls. Differential diagnosis included metastasis from previous gallbladder cancer, primary sclerosing cholangitis, Caroli disease, and hepatolithiasis. The extrahepatic ducts were normal. Because the diagnosis was unclear and the patient needed biliary decompression, he underwent ERCP and Spyglass (Boston Scientific, Marlborough, Mass) cholangioscopy (Video 1), which demonstrated fleshy intraluminal polypoidal mass lesions (Fig. 2) in the right anterior and right posterior intrahepatic ducts and at the origin of the