Purpose: Clinical Vignette: Sarcoidosis is a multisystem granulomatous disease of unknown etiology that presents most often in young adults with hilar adenopathy, pulmonary infiltrates, skin or eye lesions. Hepatobiliary involvement is asymptomatic in most, with non-caseating granulomas seen often. Cholestatic hepatitis with liver chemistry resembling PBC or PSC has been described. Intra-hepatic cholestasis, hepatosplenomegaly, pre-sinusoidal portal hypertension, portal fibrosis, and cirrhosis may be seen. Abnormalities of the large bile ducts and extra-hepatic tree is rarely seen, and we describe a Klatskin-like biliary confluence granulomatous obstruction that responded to balloon dilation, stenting, and corticosteroid therapy. Case: A 38 yr. old caucasian female presented with painless jaundice. She complained of pruritus, weakness, fatigue, dark urine and malaise. Initial labs: Bilirubin 11, AST-107, ALT-92, GGT-431 (Nl 15–85), Alk. Phos-635, CEA-1.2, Nl p-ANCA, Nl Ig's, ACE-28 (Nl 8–21); ANA, AMA, copper, Ferritin were WNL. U.S. revealed intra-hepatic duct dilations; CT and MRCP with confluence region mass effect with marked proximal ductal dilation. A 3 cm portacaval node was noted; ERCP with Spyglass cholangioscopy displayed a tight confluence stricture, with extension into the right hepatic system; After balloon dilation of both right and left ducts, cholangioscopy revealed a nodular duct wall and brushings and directed biopsy bites were collected. Histology from the confluence revealed non-caseating granulomas with chronic cholangitis; No malignancy was detected. A 10 F stent was placed into the dominant right system and the bilirubin fell from 17 to 11 mg/dl overnite. The pateint was treated with Urso and 40 mg of Prednisone. Follow-up 2 weeks later: Bili.-1.5, GGT-135, ALT-48. Conclusions: Sarcoidosis is a chronic granulomatous disease that may present in young adults as a hepatocellular or cholestatic process. Extra-hepatic biliary obstruction may result from peri-ductal adenopathy or from ductal infiltration. Cholangioscopy may prove beneficial in directing biopsies and/or brushings to rule out carcinoma. Biliary sarcoidosis appears to be exquisitely sensitive to biliary stent decompression and corticosteroids.