In this situation, a trans-hepatic approach can allow wire-guided sphincterotomy leading to successful endoscopic management and the avoidance of open bile duct surgery. This presentation will describe the technical aspects of this approach together with illustrative case examples. The technique has a very high success rate with complications of haemorrhage, bile leak and cholangitis in approximately 10% of patients. Polya-gastrectomy is declining in its incidence and experienced endoscopists who can deal with these patients are becoming uncommon. A transhepatic approach may allow a guide wire to be passed along the afferent loop for endoscopic access. There is a small but growing experience of EUS-guided biliary drainage for the management of biliary obstruction. Gastroenterologists favour this approach because it appears to generate fewer complications than a trans-hepatic approach and is certainly less uncomfortable for the patient. These newer techniques will be illustrated and discussed. The concept of reference dose levels was introduced in the UK to act as an aid to radiation protection. Initially, DRL were calculated for common diagnostic x-ray examinations and in more recent years the concept has been extended into interventional studies. The aim of DRL was to indicate abnormally high doses for common x-ray examinations. Recent literature states that DRLs are still very variable across Europe and Asia for common examinations using similar x-ray equipment. Hence, patients are consistently receiving higher radiation doses in different countries. It has also been reported that poor image quality results in unnecessary radiation exposure to these patients. Simple measures can be put in place by the radiographer to ensure that image quality is maintained and the ALARA principle is adhered to at an international level. The use of anti-scatter grids, standardised techniques, DRLs and the impact of digital imaging will be explored and recommendations for best practice made. These simple modifications to technique can be easily implemented into daily practice in the imaging department and have achieved dose reductions of up to 49% with minimal loss of image quality during simulated experimental conditions. The session will conclude with a discussion on the concept of producing a diagnostic image which is adequate for the purpose with a lower radiation dose, rather than optimum image quality with a high radiation dose.