A 92-year-old female with history of Atrial fibrillation presented to our emergency department with the complaint of scant hemoptysis of 1-day duration. She reported a 1-week history of 4-pound unintentional weight loss, but denied fever, chills, night sweats, abdominal pain, light-colored stools or dark urine. She was found to have minimal jaundice. Laboratory workup showed total bilirubin of 7.8, alkaline phosphatase 570, ALT 364. CA19-9 was 339. A Commuted tomography scan showed a 1.8 x 1.6 cm mass arising from the head of the pancreas with intra and extrahepatic biliary ductal dilatation with double duct sign. Endoscopic Ultrasound demonstrated that the main pancreatic duct terminated in the minor papilla consistent with pancreas divisum. Fine needle aspiration (FNA) of the pancreatic mass was performed. She underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) with sphincterotomy and stent placement (Figure 1). Paradoxically, her total bilirubin increased to 14.2. ERCP was repeated and it showed a stent placed in a very low-inserted cystic duct (LICD) at the level of the papilla (Figure 2). The stent was removed, and a new bare metal stent was inserted in the true common bile duct (CBD), or more accurately, the common hepatic duct (CHD). Flow is demonstrated in the biliary tree and to bypass the gallbladder (Figure 3). Total bilirubin improved to 2.6. Pathology from the FNA was suspicious for adenocarcinoma. The patient was discharged in good condition with plans for outpatient follow-up with surgery and oncology. The cystic duct's union with CHD can be abnormally proximal (near the porta hepatis or into the right hepatic duct), or distal (lower third of the CBD, intrapancreatic, or intraduodenal). ERCP is the gold standard tool for identifying anatomic variants of the biliary tree. In a recent study of patients with clinical biliary symptoms, the rate of LICD was found to be 5.4% by ERCP. An LICD, just above the level of the pancreas, causing malpositioning of a biliary stent, has been reported in the literature and is very rare. Here, we demonstrate a similar case of inadvertent placement of a biliary stent in an accessory cystic duct that joined the CHD at the level of the duodenal papilla. This case highlights the importance of verification of contrast flow into the biliary tree after stent placement. In our case, this complication occurred despite contrast flow into the biliary tree due to back flow of contrast into the true CBD.Figure 1Figure 2Figure 3