Copyright 2014 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited. Obstructive Jaundice in a 3-Month-Old Baby A previously well 3-month-old girl presented with diarrhea, progressive pale stools, weight loss, and jaundice. Preliminary investigations showed obstructive cholestatic jaundice with increased g-glutamyl transferase activity, conjugated bilirubin, and bile salts. A magnetic resonance cholangiography showed dilation of the main bile duct with a sudden narrowing in the distal segment and no signs of biliary stones and extrinsic compression (Fig. 1). Intraoperative cholangiography (Fig. 2) confirmed the presence of a distal choledochal stricture without signs of choledochal cysts. A duodenotomy was performed with transpapillary dilatation of the stenotic segment. Subsequently a cholecystectomy was carried out and a T tube was positioned via the remnant of the cystic duct to drain the bile and to stent the dilated segment. No sludge or stones were obtained after the CBD dilatation. After 1 month, T tube was removed without complications, and the results of follow-up ultrasound studies showed no dilation of the biliary tract. Liver blood test quickly normalized and remained stable after T tube removal. At last follow-up visit, 9 months after surgery, total bilirubin was 0.51 mg/dL, conjugate bilirubin was 0.03 mg/dL, and g-glutamyl transferase activity was 8 U/L. In our patient, biliary atresia, choledochal cyst, and extrinsic compression were excluded by radiologic studies. Inflammatory choledochal stricture has been described in infants (1 – 3), but it seems unlikely in our patient given the precocious age at presentation and the site of stricture. Isolated congenital distal choledochal stricture is the most probable diagnosis (4). Our case is one of the few reported and highlights the need for a conservative approach in such a rare and not well- known disease. Submitted by:  Alessandro Amaddeo,  Elisa Rubinato, y Jurgen Schleef, y Damiana Olenik,  Domenica Giglia,  Federico Marchetti, and  Alessandro Ventura  Department of Pediatrics, and { Department of Pediatric Surgery, Institute for Maternal and Child Health—IRCCS ‘‘Burlo Garofolo,’’ University of Trieste, Trieste, Italy. Address correspondence and reprint requests to Alessandro Amaddeo, MD, Department of Pediatrics, Institute for Maternal and Child Health, IRCCS ‘‘Burlo Garofalo,’’ University of Trieste, Trieste, Italy (e-mail: alessandro.amaddeo@gmail.com). The authors report no conflicts of interest. Submissions for the Image of the Month should include high-quality TIF endoscopic images of unusual or informative findings. In addition, 1 or 2 other associated photographs, such as radiological or pathological images, can be submitted. A brief description of no more than 200 words should accompany the images. Submissions are to be made online at www.jpgn.org, and will undergo peer review by members of the NASPGHAN Endoscopy and Procedures Committee, as well as by the Journal. REFERENCES 1. Krishna RP, Lal R, Sikora SS, et al. Unusual causes of extrahepatic biliary obstruction in children: a case series with review of literature. Pediatr Surg Int 2008;24:183–90. 2. Standeld NJ, Salisbury JR, Howard JR. Benign non-traumatic inammatory strictures of the extrahepatic biliary system. Br J Surg 1989;76:849–52. 3. Bowles MJ, Salisbury JR, Howard ER. Localized, benign, non traumatic strictures of the extrahepatic biliary tree in children. Surgery 2001;130:55–9. 4. Va ´zquez Rueda F, Paredes Esteban RM, Escassi Gil A, et al. Isolated congenital stenoses of the extrahepatic bile ducts. Cir Pediatr 1993;6:40–3. Copyright # 2014 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition DOI: 10.1097/MPG.0b013e31827e1ec6 FIGURE 1. Magnetic resonance cholangiography showing dilation of the common bile duct (^, maximum proximal dilation of 5 mm), with a sudden narrowing on the distal segment. Common hepatic duct () and the gallbladder (>) are dilated. FIGURE 2. Intraoperative cholangiogram showing dilation of common hepatic duct (), cystic duct (8), and gallbladder (>). Common bile duct (^) appears dilated with a sudden narrowing at the end. IMAGE OF THE MONTH JPGN  Volume 59, Number 3, September 2014 e31