Most modern sphincterotomes have two to three lumens to enable simulatenous passage of contrast and wire into the bile duct. Traditionally, contrast was first injected to confirm that the bile duct as opposed to the pancreatic duct had been accessed. In 2004 Lella randomized 400 patients to the standard approach of contrast injection versus the passage of the guidewire to confirm bile duct cannulation.5 In the contrast group 4% of patients developed pancreatitis compared to none in the wire guided group and high pancreatic enzyme levels (5 times the upper limit of normal) developed in 20% of contrast guided versus 5% of wire guided cases. Subsequent large randomized trials have consistently demonstrated post ERCP pancreatitis rates of 2-9% in wire guided versus 10-17% in contrast guided ERCP.6-7 Wire guided cannulation has also been shown to shorten cannulation and fluoroscopy times.8