A 71-year-old female with a history of Roux-en-Y gastric bypass (RYGB, 1999) and decompensated cirrhosis with ascites, presented with severe obstructive jaundice with CT showing distal common bile duct (CBD) stricture with marked upstream dilation. Single-balloon enteroscopyassisted ERCP (Figure 1) was performed that confirmed a distal CBD stricture and multiple 7Fr double-pigtail plastic stents were placed (Figure 2). Subsequently, she required a repeat procedure for stent replacement two months later. The patient’s ERCPs have been challenging given long-limb RYGB and friable GI mucosa with touch friability, and easy and excessive bleeding during procedures. Further work-up, including exploratory laparotomy, showed peritoneal metastasis with excisional biopsy of the peritoneal implant confirming metastatic adenocarcinoma.