Bile duct intraductal papillary mucinous neoplasia (BD-IPMN) is a pre-malignant precursor to cholangiocarcinoma traditionally managed by surgery with limited data on endoscopic management. We present a case of an elderly comorbid patient with long segment BD-IPMN containing high grade dysplasia who declined surgery. Cholangioscopic and fluoroscopic videos demonstrate characteristic BD-IPMN morphology, application of cholangioscopy-guided radiofrequency ablation (RFA), post-treatment appearances, and subsequent recurrence. In this case, RFA did not achieve complete eradication but substantially reduced the overall disease length, permitting a more conservative surgical resection approach. This video highlights key diagnostic features, technical considerations, and the potential role and limitations of RFA in selected patients with BD-IPMN who are poor surgical candidates.