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Endoscopic biliary drainage is difficult in patients with biliary obstruction combined with gastric outlet stricture (GOS). Endoscopic ultrasound is useful for such patients, but needs advanced technique and sophisticated equipment. This study aimed to evaluate the efficacy and safety of conventional endoscopic retrograde cholangiopancreatography (ERCP) in patients with GOS and biliary obstruction without the assistance of endoscopic ultrasound.Seventy-four patients with GOS proximal to the ampulla and biliary obstruction, including 27 with benign GOS and 47 with malignant GOS, were retrospectively enrolled. Three conventional methods were used to pass through the stricture and allow the duodenoscope to reach the papilla: adjusting the endoscope, balloon dilation, and metal stent insertion. The uncovered metal stent insertion was applied only in patients with malignant GOS. The primary outcome evaluated was successful biliary drainage.No serious complications occurred during or after ERCP. The overall success rate of biliary drainage in the patients was 81.1%. The success rate of duodenoscopy insertion by endoscope adjustment, balloon dilation, and stent insertion was 44.6, 68.9, and 71.4%, respectively. Endoscope adjustment was more successful in the patients in the benign group compared with the patients in the malignant group (60.9 vs. 35.7%). Similar findings were obtained for balloon dilation (92.3 vs. 59.4%).Most GOS, encountered during ERCP, can be safely dealt with using conventional endoscopic approaches in patients with biliary obstruction. However, the efficacy of endoscope adjustment or balloon dilation is better for benign GOS than for malignant GOS.