Hepatolithiasis is seen in recurrent pyogenic cholangitis and is often difficult to treat, frequently progressing despite therapy. It can be a source of sepsis and intrahepatic abscesses. Chronic complications, such as secondary biliary cirrhosis, lobar atrophy, and cholangiocarcinoma can develop. Situs inversus is a rare congenital condition that occurs in 1 in 10,000 to 50,000 births. We present a case of hepatolithiasis in a woman with situs inversus in order to share our experience of non-operative management using ERCP in a patient with altered anatomy. MM is a 48 year old woman with situs inversus who presented to the ER with 1 day of severe epigastric pain, nausea, and vomiting after a recent ERCP at an outside facility. Labs were significant for elevation of lipase, bilirubin, transaminases, and alkaline phosphatase. A CT scan demonstrated choledocholithiasis, with marked dilation of intra- and extra-hepatic bile ducts. The patient was admitted for post-ERCP pancreatitis and cholangitis secondary to choledocholithiasis. Repeat ERCP at our institution revealed several large intrahepatic bile duct stones, ductal dilation, and a previously placed CBD stent. The sphincterotomy was extended, lithotripsy of several stones was performed, and the original stent was exchanged for longer, bilateral biliary stents. The patient was referred to a hepatobiliary surgeon for partial hepatectomy. After multiple discussions among the patient, family members, and surgical and GI teams, a decision was reached to pursue non-operative management. A total of 13 ERCPs were performed with stone removal, lithotripsy (mechanical and electrohydraulic), balloon dilations, cholangioscopy, and stent exchanges. One large stone located in the intrahepatic bile duct required the assistance of an internal-external drain to gain access to the duct with ERCP.1267_A.tif Figure 1: Hepatolithiasis on CT abdomen/pelvis.1267_B.tif Figure 2: Cholangiogram on ERCP for hepatic stone removal1267_C.tif Figure 3: Hepatic stones on SpyGlassThe recurrence rate of intrahepatic stones after lithotripsy is approximately 22-50%. Long-term results (median follow-up of 8 years) show highest rate of stone clearance in patients who undergo hepatectomy compared with non-operative management. In our case, the patient's situs inversus presented an anatomic challenge for the hepatobiliary surgeon, while the size, number, and location of the hepatolithiasis complicated the surgical options (liver transplantation versus partial hepatectomy). ERCP was successfully used as an alternative for removal of large intrahepatic stones in this patient with abnormal anatomy.