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Adverse events related to endoscopic retrograde cholangiopancreatography (ERCP) in adults

Adverse events related to endoscopic retrograde cholangiopancreatography (ERCP) in adults
Literature review current through: Jan 2024.
This topic last updated: Oct 31, 2023.

INTRODUCTION — Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure in which a specialized side-viewing upper endoscope is guided into the duodenum, allowing for instruments to be passed through the ampulla of Vater and into the biliary and pancreatic ducts. The ducts are opacified by injecting a contrast medium, thereby achieving radiographic imaging and facilitating endoscopic therapy. ERCP-guided interventions are used for managing a variety of pancreaticobiliary disorders (eg, removal of bile duct stones, relief of biliary obstruction).

ERCP is a complex procedure that requires specialized training and experience, and it is associated with higher rates of serious adverse events than other endoscopic procedures (eg, upper endoscopy, colonoscopy). It is important to use strategies to prevent ERCP-related adverse events and to recognize adverse events early so that treatment can be initiated.

This topic will discuss adverse events related to ERCP. Other aspects of ERCP including indications, patient preparation, and post-procedure care is discussed separately. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults".)

Adverse events related to stent placement are discussed separately:

Biliary stents – (See "Endoscopic stenting for malignant biliary obstruction" and "Endoscopic management of postcholecystectomy biliary complications".)

Pancreatic stents – (See "Pancreatic stenting at endoscopic retrograde cholangiopancreatography (ERCP): Indications, techniques, and complications".)

INCIDENCE — ERCP is generally regarded as a safe procedure. However, ERCP has been associated with a higher rate of adverse events than most other endoscopic procedures despite technologic advances, adherence to safety protocols, and advanced endoscopy training programs [1].  

Reported overall rates of ERCP-related adverse events have ranged from 5 to 12 percent, and mortality rates have ranged from 0.1 to 1.4 percent [2-7]. As an example, in a systematic review of 21 studies involving 16,855 patients who underwent ERCP, the overall complication rate was 7 percent, and the rate of serious complications was 2 percent [6].

Despite technologic progress and safety measures, rates of procedure-related mortality have not decreased over time [8]. One possible reason is that ERCP has evolved into mainly a therapeutic procedure; thus, the procedure-related risks include those associated with the diagnostic examination and related interventions.

Data have suggested that all-cause mortality rates beyond 30 days post-ERCP were higher compared with rates within the 30-day window; however, deaths were most often related to underlying disease. In a registry study including over 16,000 patients who underwent ERCP, all-cause mortality rates at three months post-ERCP were higher compared with rates within 30 days (12 versus 5 percent) [9]. Most deaths that occurred beyond 30 days post-procedure were due to cancer (75 percent) [9].

RISK FACTORS — Some ERCP-related events are due to the effect of procedural sedation (eg, hypotension), while others are due to the endoscopy itself or to an intervention.

Observational studies have identified and classified risk factors for ERCP-related adverse events [5,8,10-19]:

Procedure-related factors (eg, difficult cannulation, precut [access] sphincterotomy). (See "Management of difficult biliary access during ERCP in adults".)

Patient-related factors (eg, surgically-altered anatomy, sphincter of Oddi dysfunction, periampullary diverticulum, cirrhosis, older age, end-stage kidney disease).

Hospital- and advanced endoscopist-related factors (eg, low ERCP case volume, procedure timing for selected conditions [eg, acute cholangitis]) [20].

Hospital and endoscopist procedure volume has been linked to risk of adverse events [21-23]. In a systematic review including 13 studies and nearly 60,000 ERCPs, higher endoscopist-related procedure volume was associated with lower risk of adverse events compared with lower procedure volume (ie, ranging from <25 to <156 ERCPs annually) (odds ratio [OR] 0.65; 95% CI 0.50-0.83) [22].

Adverse events related to ERCP have also been characterized based on the following factors [24,25]:

Location – Adverse events may be focal, occurring at the point of endoscopic contact (eg, perforation, bleeding, pancreatitis), or they may affect an organ system (eg, cardiopulmonary) that was not accessed by the endoscope or its related devices.

Timing – Adverse events may occur early (typically within 30 days after the procedure) or late (beyond 30 days).

Severity – The severity of adverse events can be assessed by duration and type of hospital stay (eg, intensive care unit); blood transfusion requirement; need for surgical, radiologic, or endoscopic interventions; and rates of morbidity and mortality [25].

COMMON ADVERSE EVENTS — The most frequently encountered adverse events related to ERCP are pancreatitis, bleeding, infection, and perforation [2-5,7].

Pancreatitis — Acute pancreatitis is a serious adverse event of ERCP that may result from mechanical injury to the pancreatic duct, hydrostatic injury from contrast injection, or guidewire manipulation. Risk factors, prevention, and management of post-ERCP pancreatitis are discussed separately. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis".)

Bleeding — Bleeding during ERCP is typically related to instrumentation such as biliary and/or pancreatic sphincterotomy. Prevention and management of post-ERCP bleeding are discussed separately. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding".)

Perforation — ERCP may be complicated by perforation of the esophagus, stomach, duodenum, or bilio-pancreatic area. The risk factors, diagnosis, and management of post-ERCP perforation are presented separately. (See "Post-ERCP perforation".)

Infection — Infections occurring after ERCP may be related to incomplete drainage of an infected biliary system, obstruction of the cystic duct, infected pancreatic fluid collection, or rarely, contaminated endoscopic equipment. The prevention and management of infectious complications related to ERCP are discussed separately:

(See "Infectious adverse events related to endoscopic retrograde cholangiopancreatography (ERCP)".)

(See "Preventing infection transmitted by gastrointestinal endoscopy".)

(See "Antibiotic prophylaxis for gastrointestinal endoscopic procedures".)

Anesthesia-related events — Anesthesia-related events are commonly reported but most are transient and managed without further complications [26-28]. In a cohort study including 528 patients undergoing ERCP, 120 sedation-related adverse events (eg, hypotension, hypoxemia) were reported (25 percent), but these events were generally minor and rarely resulted in termination of the procedure [27]. Complications related to procedural sedation and anesthesia are discussed in more detail separately [29]. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Complications' and "Adverse events related to procedural sedation for gastrointestinal endoscopy in adults".)

LESS COMMON ADVERSE EVENTS

Accessory-related issues

Impaction of a stone retrieval basket — During ERCP-guided extraction of difficult bile duct stones (table 1), the basket/stone apparatus may rarely become trapped in the biliary tree, typically at the ampulla within the intraduodenal portion of the common bile duct (image 1). Basket entrapment in other locations (eg, proximal bile duct, intrahepatic ducts, main pancreatic duct) has also been reported [30,31].

Risk factors for basket entrapment include large, irregularly shaped and/or multiple stones, in addition to a small sphincterotomy size. Other risk factors are distal narrowing of the common bile duct and segmental dilation of intrahepatic ducts (eg, Caroli disease). (See "Caroli disease", section on 'Patients with choledocholithiasis and cholangitis'.)

Techniques for using a basket device and measures to reduce the risk of basket entrapment are discussed separately. (See "Endoscopic management of bile duct stones", section on 'Patients with complicated stones'.)

Management of basket retention is individualized and informed by location of impaction, endoscopist preference, and equipment availability [32-34]. We may use mechanical lithotripsy to fragment the stone in addition to extending the sphincterotomy or performing sphincteroplasty, and these methods are discussed separately. (See "Endoscopic management of bile duct stones", section on 'Fragmenting the stones' and "Endoscopic balloon dilation for removal of bile duct stones" and "Endoscopic biliary sphincterotomy".)

Other nonsurgical interventions include cholangioscopy-guided electrohydraulic lithotripsy or laser lithotripsy:

(See "Cholangioscopy and pancreatoscopy".)

(See "Electrohydraulic lithotripsy in the treatment of bile and pancreatic duct stones".)

(See "Laser lithotripsy for the treatment of bile duct stones".)

When advanced endoscopic methods are unsuccessful or unavailable, surgical intervention with common bile duct exploration is needed [33].

For patients with incomplete clearance of the bile duct, we establish biliary drainage by placing a temporary stent. (See "Endoscopic management of bile duct stones", section on 'Patients with incomplete duct clearance'.)

Events related to wire-guided cannulation — Rare guidewire-related adverse events include:

Inadvertent cannulation – Advancing the guidewire inadvertently through the bile or pancreatic duct and into the liver or pancreatic parenchyma or into an adjacent vessel may result in bleeding, hematoma, bile leak, or pancreatitis [35-39]. However, perforation of the bile or pancreatic duct rarely occurs because wire-guided cannulation is performed under fluoroscopic guidance. If a small ductal perforation occurs, we immediately remove the guidewire and observe the patient for complications such as bleeding and peritonitis. Most patients recover without the need for surgery [39]. (See 'Extraluminal bleeding and hematomas' below.)

Guidewire fracture – Guidewire fracture during ERCP has been reported rarely [38,40-43]. Limited studies suggested that guidewire fragments retained within the pancreatic or biliary ducts may be removed endoscopically without the need for surgery [40,41,43].

Stent-related issues — Adverse events related to stent placement (eg, stent migration, stent occlusion) are discussed separately:

Biliary stents – (See "Endoscopic stenting for malignant biliary obstruction", section on 'Stent-related' and "Endoscopic management of postcholecystectomy biliary complications".)

Pancreatic stents – (See "Pancreatic stenting at endoscopic retrograde cholangiopancreatography (ERCP): Indications, techniques, and complications", section on 'Adverse events'.)

Contrast allergy and other contrast-related issues — Adverse reactions to contrast agents used during ERCP are very rare because contrast agents are not injected intravenously but instead are used to opacify the biliary and pancreatic ducts [44-47]. In a study of 1766 patients who underwent a total of 2295 ERCPs, one adverse reaction to contrast (ie, a diffuse pruritic rash) was reported, but there were no cases of anaphylaxis [45]. In addition, no adverse reactions related to contrast media occurred in 127 procedures performed in patients with a history of iodine allergy. Most procedures (95 percent) were performed without premedication prophylaxis.

Thus, use of premedication varies in clinical practice because it is uncertain whether it is beneficial for preventing adverse reactions related to contrast. We reserve the use of premedication for patients with a history of anaphylaxis or severe adverse reaction (eg, bronchospasm, diffuse erythema with hypotension) related to iodinated contrast. The premedication regimens are similar to prophylaxis for patients undergoing computed tomography with iodinated contrast and involve administration of an antihistamine and glucocorticoid (table 2). The timing of ERCP (urgent or elective) also informs drug dosing and administration, and these issues are discussed in detail separately. (See "Patient evaluation prior to oral or iodinated intravenous contrast for computed tomography".)

We do not typically use premedication for patients with a history of nonsevere reaction to iodinated contrast (eg, limited rash, pruritus, cutaneous edema or flushing) [45].

Extravasation of contrast into the duodenal wall surrounding the papilla during ERCP may interfere with successful biliary cannulation, prolong the procedure, and possibly increase the risk of adverse events [11,48]. In addition, injecting contrast inadvertently into a vascular structure may create diagnostic uncertainty and increase the risk of sepsis, gas embolism, bleeding, or thrombosis. As an example, a portal vein that has been opacified with contrast may be misinterpreted as an incompletely filled bile duct (picture 1).

If contrast is inadvertently injected into a vascular structure, we terminate the ERCP and monitor the patient for adverse events such as bleeding or infection.

Dysfunction of implanted cardiac devices — During procedures involving an electrosurgery unit, the function of a cardiac implantable electronic device (CIED) may be affected by electromagnetic interference (EMI). EMI refers to the potential dysfunction of an electronic device when it is in the vicinity of an electromagnetic field generated by an external source. During ERCP with sphincterotomy, we use monopolar current from an electrosurgical unit.

Patients with CIEDs (ie, pacemakers or implantable cardioverter defibrillators) undergo a preprocedure evaluation to assess compatibility with use of an electrosurgery unit (table 3). Periprocedural management of patients with implanted cardiac devices who undergo procedures involving electrosurgery is discussed in more detail separately. (See "Perioperative management of patients with a pacemaker or implantable cardioverter-defibrillator".)

Data have suggested that use of an electrosurgery unit during endoscopy rarely impacts the function of cardiac implanted electronic devices [49-52]. In a database study including over 40,000 reports of CIED dysfunction, 45 reports (approximately 0.1 percent) were related to use of electrocautery during an endoscopic procedure. Events related to electromagnetic interference included inappropriate shocks, pacing inhibition resulting in bradycardia or asystole, device damage requiring replacement, and rarely, ventricular tachycardia [50]. Although most pacemakers are not affected by short bursts of electrocautery, cardiac arrhythmias can develop if a monopolar current passes through the pacemaker or the heart. In addition, electrocautery may trigger activation of an implantable cardioverter defibrillator.

Extraluminal bleeding and hematomas — Bleeding after ERCP is usually related to endoscopic sphincterotomy and thus involves bleeding into the duodenal lumen. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding".)

However, rare causes of post-ERCP bleeding have been related to the following conditions:

Splenic or liver injury – Cases of splenic, hepatic, or other intrabdominal injury resulting in bleeding have been reported following ERCP [53-63]. The proposed mechanism of injury is related to excessive manipulation and/or looping of the endoscope within the stomach while advancing it into the duodenum. The manifestations of splenic injury vary from a subcapsular hematoma to rupture of splenic vessels. As a result, some patients will develop hemodynamic instability and/or acute abdomen, but other patients will have less severe symptoms. The diagnosis of a subcapsular splenic laceration should be suspected in patients who develop acute left upper quadrant abdominal pain following ERCP. The pain is often delayed (ie, >24 hours after the procedure) and is not always associated with signs of peritoneal irritation, hemodynamic instability, or a drop in hemoglobin. Similarly, subcapsular hepatic hematoma is a potentially serious complication, and may be related to use of a guidewire [55-57]. (See 'Accessory-related issues' above.)

For patients with suspected intra-abdominal bleeding, the initial evaluation includes imaging with computed tomography (CT) scan with angiography in addition to selective angiographic intervention for the culprit vessel. For some patients, surgical intervention may be required to achieve hemostasis if the bleeding cannot be controlled with angiographic methods. (See "Management of hepatic trauma in adults".)

Biliary varices – Bleeding from bile duct varices during ERCP has been reported following sphincterotomy and dilation of a distal common bile duct stricture in a patient with cirrhosis and cavernous transformation of the portal vein [64-66].

Bleeding related to stent placement – Bleeding related to biliary or pancreatic stent placement is uncommon but may result from the stent becoming impacted in or irritating the opposing duodenal wall. Stent-related bleeding from mucosal damage in the distal small bowel or colon has also been reported as a result of stent migration [67]. In addition, self-expandable metal stents may rarely cause hemobilia related to a pseudoaneurysm that formed an arterio-biliary fistula [68,69]. Pseudoaneurysms have also been reported in patients with difficult biliary access requiring precut sphincterotomy followed by plastic stent placement [70].

During stent placement, acute bleeding may be related to vascular injury (eg, communication with the portal vein). For such patients, we place a fully covered, self-expandable metal stent (SEMS) to tamponade the bleeding and cover the fistula tract. For patients with refractory bleeding despite stenting, management is similar to patients with refractory post-sphincterotomy bleeding with subsequent options including angiographic embolization or surgery [71]. (See "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding", section on 'Refractory bleeding'.)

Intramural injury – Intramural hematoma of the upper esophagus as a result of ERCP has been reported [72]. The risk of injury to the esophageal wall may be increased with ERCP because visualization of the esophageal mucosa is limited during side-viewing endoscopy.

Gas embolism

Epidemiology and risk factors — Gas embolism is a rare but potentially catastrophic event resulting from communication of the vasculature with external pressure from the gastrointestinal lumen or bile duct that allows gas to enter the circulation [73,74]. The embolized gas is typically carbon dioxide because most endoscopists use carbon dioxide for insufflation during ERCP. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults", section on 'Gas insufflation'.)

Most cases of gas embolism related to endoscopic procedures involve ERCP, although some case reports have been related to upper or lower gastrointestinal endoscopy [75-80]. As an example, in an analysis of an inpatient database including over two million endoscopic procedures, gas embolism occurred in 13 patients, resulting in a gas embolism rate of 0.57 per 100,000 endoscopies. Gas embolism was more common during ERCP compared with upper endoscopy or colonoscopy (3.32 per 100,000 procedures versus 0.44 and 0.38 per 100,000 procedures, respectively) [78]. However, the true incidence of gas embolism is uncertain because some cases may be subclinical and thus go unreported [81]. Males and females appear to be affected equally [79].

Risk factors for gas embolism may be classified as follows [82-85]:

Procedure-related factors – Intraductal endoscopy using small caliber endoscopes (eg, cholangioscopy), gas insufflation using higher pressures during prolonged procedures, or use of a rendezvous technique for establishing biliary access. (See "Therapeutic endoscopic ultrasound", section on 'EUS-guided cholangiopancreatography'.)

Patient-related factors – Prior hepatobiliary intervention (eg, hepatobiliary surgery, liver biopsy, percutaneous transhepatic cholangiography with biliary drain(s), transjugular intrahepatic portosystemic shunt [TIPS]), history of blunt or penetrating trauma to the liver, or history of liver abscesses/tumor.

Possible protective/mitigating factors include:

Carbon dioxide insufflation – We routinely use carbon dioxide for gas insufflation during ERCP because the consequences of gas embolism may be mitigated with use of carbon dioxide rather than air insufflation [86]. Carbon dioxide is rapidly absorbed by the gastrointestinal mucosa and delivered to the lungs by the circulation, whereas ambient air is not readily absorbed. Thus, carbon dioxide is more rapidly eliminated if embolism occurs. (See "Anesthesia for gastrointestinal endoscopy in adults", section on 'Complications'.)

Other aspects of carbon dioxide insufflation for gastrointestinal procedures are discussed separately. (See "Overview of endoscopic retrograde cholangiopancreatography (ERCP) in adults", section on 'Gas insufflation' and "Overview of colonoscopy in adults", section on 'Colonoscope advancement and mucosal inspection'.)

Types of gas embolism and pathogenesis — Gas embolism may be venous or arterial [79]:

A venous gas embolism occurs when gas passes from the portal vein to the systemic venous circulation through the hepatic veins and then to the right ventricle and pulmonary circulation.

An arterial gas embolism occurs when gas in the venous system enters the arterial system through a patent foramen ovale or pulmonary arteriovenous shunts; it may also occur in the absence of a shunt if the rate and volume of gas entry exceeds the filtering capacity of the lung.

Possible mechanisms for gas embolism during an endoscopic procedure include:

Insufflating the gastrointestinal lumen with gas under pressure leads to gas entering veins that are exposed because of a compromised mucosal barrier (eg, mucosal irritation, ulceration).

Gas enters a previously established communication between the biliary system and the circulation (eg, bilio-venous fistula).

During intraductal biliary endoscopy (eg, cholangioscopy), gas enters a hepatic vein.

Clinical presentation — Clinical presentation of gas embolism ranges from patients with no or minimal symptoms from a minor venous gas embolism to respiratory compromise, ventricular arrhythmias, and cardiac arrest in severe cases [79]. The specific clinical manifestations depend on the rapidity and amount of gas entering the circulation in addition to underlying comorbidities (table 4) [87,88]. (See "Air embolism".)

During ERCP, the onset or exacerbation of symptoms may occur when changing the patient's position from the typical prone positioning to a supine position. (See "Anesthesia for gastrointestinal endoscopy in adults".)

Diagnosis and management — Gas embolism should be suspected in patients who develop sudden hemodynamic collapse during or immediately following an endoscopic procedure. When gas embolism is suspected, the procedure is terminated immediately in addition to administering 100 percent oxygen, and turning the patient to the left lateral decubitus position, head down. Management of gas embolism during ERCP is similar to other settings as shown in the table (table 5). (See "Intraoperative venous air embolism during neurosurgery", section on 'Management of intraoperative VAE'.)

While rare, endoscopy-related gas embolism has been associated with high mortality rates. In a large database study including patients undergoing gastrointestinal endoscopy, gas embolism occurred rarely (0.57 per 100,000 procedures) but the mortality rate among patients with gas embolism was 15 percent [78].

Prevention — Strategies to reduce the risk of gas embolism include [63]:

Continuous cardiopulmonary monitoring to promote early detection

Avoiding ERCP in patients with suspected or known biliary-vascular fistula

Use of carbon dioxide insufflation for ERCP (see 'Epidemiology and risk factors' above)

Pneumothorax — Pneumothorax (gas in the pleural space) or other gas leak (eg, subcutaneous emphysema, pneumoperitoneum) with or without gastrointestinal perforation has been rarely reported following ERCP and other endoscopic procedures [89-91]. The mechanism of injury leading to pneumothorax in the absence of perforation is a rise in airway and intra-alveolar pressure leading to rupture of pulmonary blebs. (See "Pneumothorax in adults: Epidemiology and etiology".)

Pneumothorax should be suspected in patients with acute dyspnea and pleuritic chest pain. Management depends on the size of the pneumothorax and associated symptoms. These issues are addressed in detail separately. (See "Clinical presentation and diagnosis of pneumothorax" and "Treatment of primary spontaneous pneumothorax in adults".)

Data on pneumothorax related to ERCP are limited to case reports. In a systematic review of 44 studies including patients undergoing ERCP, a total of 49 cases of pneumothorax were reported [90]. Twenty-one patients (43 percent) had altered gastrointestinal anatomy (eg, periampullary diverticula, surgically altered anatomy). Pneumothorax occurred bilaterally in 22 patients (45 percent). The cause of pneumothorax in most cases was duodenal perforation at a periampullary site in 20 procedures (41 percent) or distal to the papilla in 11 procedures (23 percent). Most patients with pneumothorax (80 percent) were diagnosed within six hours of ERCP, and 30 patients underwent pleural drainage.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Endoscopic retrograde cholangiopancreatography (ERCP)".)

SUMMARY AND RECOMMENDATIONS

Background and incidence – ERCP is generally regarded as a safe procedure. However, ERCP is associated with higher rates of adverse events than other endoscopic procedures despite technologic advances, adherence to safety protocols, and advanced endoscopic training programs. Reported overall rates of ERCP-related adverse events have ranged from 5 to 12 percent, and mortality rates have ranged from 0.1 to 1.4 percent. (See 'Incidence' above.)

Risk factors – Risk factors for ERCP-related complications include (see 'Risk factors' above):

Procedure-related factors (eg, difficult cannulation, precut [access] sphincterotomy)

Patient-related factors (eg, surgically altered anatomy, sphincter of Oddi dysfunction, periampullary diverticulum, comorbidities such as older age and cirrhosis)

Hospital- and advanced endoscopist-related factors (eg, low ERCP case volume, procedure timing for selected conditions [eg, acute cholangitis])

Common adverse events – The most frequently encountered serious post-ERCP adverse events are:

Pancreatitis (see "Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis")

Bleeding (see "Post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding")

Infection (see "Infectious adverse events related to endoscopic retrograde cholangiopancreatography (ERCP)")

Perforation (see "Post-ERCP perforation")

Less common adverse events

Accessory-related adverse events – Uncommon adverse events involving ERCP accessories include impaction of a stone retrieval basket (image 1) and guidewire-related injuries (eg, inadvertent cannulation of intra-abdominal organs or vessels). (See 'Accessory-related issues' above.)

Contrast allergy – Adverse reactions to contrast agents for ERCP are very rare because contrast agents are not injected intravenously but instead are used to opacify the biliary and pancreatic ducts. (See 'Contrast allergy and other contrast-related issues' above.)

Gas embolism – Gas embolism is a rare but potentially serious event. Gas embolism should be suspected in patients who develop sudden hemodynamic collapse during or immediately following ERCP. When gas embolism is suspected, the procedure is terminated immediately in addition to administering 100 percent oxygen and turning the patient to the left lateral decubitus position, head down. Management of gas embolism during ERCP is similar to other settings as shown in the table (table 5). (See 'Gas embolism' above.)

Pneumothorax and other air leaks – Pneumothorax (gas in the pleural space) or other gas leak (eg, subcutaneous emphysema, pneumoperitoneum) with or without gastrointestinal perforation has been rarely reported following ERCP. Pneumothorax should be suspected in patients with acute dyspnea and pleuritic chest pain. Management depends on the size of the pneumothorax and associated symptoms. These issues are addressed in detail separately. (See "Clinical presentation and diagnosis of pneumothorax" and "Treatment of primary spontaneous pneumothorax in adults".)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledge Francesco Ferrara, MD, and Silvano Loperfido, MD, who contributed to earlier versions of this topic review.

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