BACKGROUND MRCP and EUS have replaced ERCP in the diagnosis of biliary diseases, but the latter is needed for treatment. This study evaluates a new approach in the management of common bile duct stones, by using an oblique-viewing echoendoscope. METHODS Nineteen patients with acute abdominal pain associated with increased liver tests entered the study. Evaluation of the biliary tree was performed by using an oblique-viewing echoendoscope (JF-UM20; Olympus Europe GmbH, Hamburg, Germany). When biliary stones or sludge were found, bile duct cannulation and sphincterotomy were performed in the same session. RESULTS Bile duct stones were diagnosed by EUS in 4 patients and biliary sludge in 12; the subsequent cholangiography and sphincterotomy with stone extraction confirmed the diagnosis in all patients. Bile duct cannulation failed in 1 patient. EUS showed features of chronic pancreatitis in 3 cases. The mean time for the whole procedure (EUS plus endoscopic retrograde cholangiography with biliary treatment) was 27 minutes. No procedure-related complications were observed. CONCLUSION This new approach appears to be feasible and safe, providing an accurate diagnosis and, at the same time, an appropriate treatment of common bile duct stones when needed. With technical improvements, this extended EUS technique could be used as the first-line procedure in patients with biliopancreatic diseases.