52-yr-old male presented with low-grade fever (100°F) for 3-4 days. He had DCD (donation after cardiac death) donor liver transplant with duct-to-duct anastomosis 2 months ago for hepatitis C related cirrhosis and hepatocellular cancer. Explant pathology revealed T1N0M0 stage. Postoperatively, immunosuppressive regimen used was steroids and tacrolimus as per protocol. Physical examination was unremarkable. Laboratory investigations revealed normal while cell count but increased serum bilirubin from 1.1 to 5.2 (0.3–1.2 mg/dL). Other liver tests revealed AST 72 (15–41 U/L), ALT 167 (17–63 U/L) and alkaline phosphatase 143 (32–91 U/L). Renal function studies showed BUN of 16 (6–20 mg/dL) and serum creatinine of 0.78 (0.64–1.27 mg/dL). Ultrasound and Doppler examination showed nondilated bile ducts and normal velocities in the portal vein and hepatic artery. Endoscopic retrograde cholangiopancreatography (ERCP) was performed based on clinical suspicion of biliary anastomotic stricture. Cholangiogram was obtained which showed a moderate sized filling defect in the mid CBD area. Read more. . .