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How to access the common bile duct

Biliary access is a prerequisite to all endoscopic interventions in the biliary tract. Successful cannulation of the papilla of Vater is the predominant challenge for the majority of endoscopists training in endoscopic retrograde cholangiopancreaticography (ERCP), and the skills required for success differ substantially from those of regular luminal endoscopy. This paper reviews some of the key elements to successful biliary cannulation, a range of options for problem-solving when cannulation is difficult, and some tips and tricks in select special situations as well. The techniques are described, and available evidence is reviewed.