EUS is a minimally invasive technique with a low morbidity (the rate of complications is less than 1 in 2000)1 with proven efficacy in the diagnosis of pancreatic diseases, and in particular of disease involving the head of the pancreas.2-7 EUS has also proven effective in the diagnosis of extrahepatic cholestasis.8-13 The examination is performed with the patient in the left lateral decubitus position under mild intravenous sedation with midazolam and/or propofol. In the absence of duodenal stenosis, the transducer is positioned in the lower part of the second segment of the duodenum so that the uncinate process and the ampullary region can be examined in addition to the distal part of the main pancreatic duct and common bile duct (CBD) (Fig. 1). With the US probe positioned in the genu superius, the CBD can be examined in longitudinal sections as far proximally as the hepatic duct and distally to the ampulla. In addition, the “porta hepatis” with the cystic duct, the fundus and neck of the gallbladder, the portal vein, the hepatic artery, and the gastroduodenal artery can also be clearly visualized from this position (Fig. 2). Withdrawal under traction from the bulb allows examination of the gallbladder and CBD, from its origin in the hilum to the convergence of the cystic duct and hepatic duct and the proximal portion of the CBD (Fig. 3). By using this method, the hepatic duct and CBD can be visualized in 95% to 100% of patients as reported in several studies.10-14 By using high frequencies (7,5, and 12 MHz), the resolution of biliary EUS is less than 1 mm, ensuring EUS as the leading imaging technique of those currently available. The limitations of biliary EUS have been clearly established14 and include (1) poor performance in the diagnosis of bile duct obstruction in the hilum or right hepatic duct;15 (2) inadequate visualization of the distal portion of the CBD when the pancreas is highly calcified and very poor visualization of the upper part of the CBD in severe necrotic acute pancreatitis; (3) difficulty in performing a biliary examination after gastrectomy with gastroenterostomy,