We present a 36-year-old woman with right upper quadrant pain, nausea, vomiting and anorexia. Significant past medical history includes morbid obesity, status post laparoscopic sleeve gastrectomy (14 months ago) with an accompanying 70 pounds weight loss. The postoperative course was complicated by a portal vein thrombosis, which was treated with Apixaban for 3 months. She was non-complaint in her followup. The patient now presents 6 months later with these symptoms. On examination, right upper quadrant tenderness was present with negative murphy sign, Patient had normal white blood count and liver function tests. Initial evaluation included a right upper quadrant ultrasound, which showed cholelithiasis without gallbladder wall edema or pericholecystic fluid. The surgical consult agreed that there were no signs of acute cholecystitis. Computed tomography (CT) demonstrated no acute abdominal process. Cavernous transformation of the main portal vein with numerous abdominal varices was seen. Additional findings included mild splenomegaly and cholelithiasis without evidence of cholecystitis. (Figure 1) A Magnetic Resonance Venography (MRV) was performed which revealed Cavernous transformation of the main portal vein with multiple collateral vessels as well as multiple portosystemic collateral vessels within the anterior abdomen and anterior body wall. Given a suspicion for a biliary process as a source of her right upper quadrant pain, she was referred for an endoscopic retrograde cholangiopancreatography (ERCP). ERCP was performed and revealed smooth narrowing of the common bile duct on the cholangiogram (Figure 2). In order to more fully characterize the stricture a cholangioscopy was performed. Cholangioscopy revealed a smooth extrinsic compressible common bile duct mass consistent with intraductal varix (Figure 3). The decision was made to perform intraductal endoscopic ultrasound (IDUS) using the ultrasound probe. The probe was advanced in the bile duct under fluoroscopic and endoscopic guidance and revealed periductal dilated intravascular spaces compressing the distal common bile duct. (Figure 4) The patient was referred to IR for a trial of portal vein recanalization that was not successful, the patient then underwent a successful Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure. This case also showed extensive involvement of the pericholecystic, peripancreatic, intra and extra hepatic venous system causing the cavernous transformation.