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Background
Pathology affecting the gallbladder and biliary system can lead to many life-threatening conditions. Understanding the anatomy and physiology underlying biliary pathology is essential to guide intervention. Many patients with acute cholecystitis are not surgical candidates are managed with lifelong percutaneous cholecystostomy tube placement. This places a huge burden on patients and their families with tube maintenance and traveling for care, as routine exchanges to prevent bacterial colonization are required for the rest of the patient's life. Endoscopic cholangiographic imaging and intervention can be used to diagnose underlying biliary pathology and can be used to guide gallstone removal. These interventions can help improve patients' quality of life and lead to eventual cholecystostomy tube removal.

Educational Goals / Teaching Points
Familiarize radiologists with biliary anatomy and the role of cholangiographic and cholangioscopic imaging, and how the use of advanced biliary endoscopy can guide treatment intervention, such as stricture dilatation, video assisted biopsy, laser lithotripsy, and percutaneous gallstone extraction in patients pursuing nonoperative management of biliary pathology. Review advanced biliary endoscopy technique, imaging optimization and protocol for evaluation of biliary pathology. Correlation between characteristic imaging findings of various biliary tract pathologies diagnosed on ultrasound, intraprocedural cholangiogram, to intraprocedural cholangioscopic images, focusing on biliary stones, stricture, and tumors.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Biliary anatomy and an overview of biliary drainage. Pathophysiology of biliary pathology with imaging correlation (cholelithiasis, intrahepatic, and extrahepatic biliary pathology), and biliary pathology following liver transplant. Algorithm for biliary and cholecystostomy drain management in nonoperative candidates focusing on patients with acute cholecystitis, and liver transplant patients with biliary duct injury or other acute pathology. Long-term management of these patients and role of imaging in postintervention assessment and surveillance (stricture restenosis, tube occlusion). Review of common postprocedural complications (bleeding, infection, tube retraction, dislodgment, biliary leak, dropped stones, cholangitis, etc).

Conclusion
Understanding of biliary pathophysiology is essential to guide intervention. Cholangioscopic imaging and intervention is a novel technique for imaging and diagnosing biliary and gallbladder pathology.