Background: Therapeutic ERCP is technically complex. A variety of techniques can be used to achieve biliary access when direct cannulation is difficult. Pre-cut papillotomy can provide immediate access, but this technique is associated with an increased risk of complications. Methods: An intramural incision technique is described that uses the false tract created with a guidewire to place a papillotome though the intramural portion of the papilla and unroof the biliary orifice. Observations: Biliary access was achieved in 6 consecutive patients in whom access could not be obtained with either a papillotome or guidewire. No major complication occurred. Conclusions: By virtue of the incision depth, the intramural incision technique offers a safer approach to biliary access than conventional pre-cut techniques. The technique is simple and will be useful when there is aberrant passage of a guidewire.