Duodenal infiltrative pattern, suspected duodenal lymphoma or carcinoma with a possibility of aggressive inflammatory disease such as transmural bacterial penetration of bowel infarction secondary post hepatic obstruction with cholecystitis. Recommend fine-needle aspirates of the duodenal wall in this patient avoiding the lumen in order to assess for monocellular versus infiltrate. Underlying lymphoma or carcinoma would be primarily suspected. If mixed inflammation is present then complicated inflammatory bowel disease would be likely. However, fine-needle aspirates would be appropriate of the pancreas. The hope is that adequate medical therapy would allow for clinical improvement if surgery is not a possibility. Surgery would involve resection of the large portion of the upper duodenum. Billroth surgery would likely not be necessary; however, resection up to the pyloric outflow would be necessary. A duodenostomy of the common bile duct would likely also be necessary as well as transposition of the primary pancreatic duct. Guarded to poor prognosis.