The picture.
A patient with painless obstructive jaundice and imaging consistent with a Bismuth II hilar stricture. Fluoroscopic ERCP characterised the stricture but could not, on appearance alone, reliably separate the leading differentials.
The cholangioscopy.
Single-operator cholangioscopy with SpyGlass DS was performed, providing direct intraductal visualisation and targeted biopsy. The intraductal appearance revised the differential, and informed the decision to proceed with bilateral self-expanding metal stenting rather than a unilateral approach.
Why this case is here
Because direct visualisation of the bile duct, when available, frequently changes management at the hilum. Fluoroscopy answers one set of questions; cholangioscopy answers a different and often more decisive one.