NOVEMBER 2026
Aim
To support the early recognition and appropriate management of post-ERCP perforation, reducing the risk of delayed treatment, clinical deterioration and preventable harm.
Background
Endoscopic retrograde cholangiopancreatography (ERCP) perforation is uncommon but well recognised and potentially fatal. Safer Care Victoria and the Victorian Perioperative Consultative Council (VPCC) have identified deaths following post-ERCP perforation.
Perforation occurs in approximately 1 in 200 ERCP procedures (0.5%). Most perforations are ampullary (65-70%) and occur following sphincterotomy or dilatation. Less commonly, perforation may result from guidewire injury to the common bile duct or from direct duodenal trauma, including injury associated with duodenal diverticula.
Abdominal pain after ERCP is commonly attributed to post-procedure pancreatitis, but perforation must also be considered. Retroperitoneal duodenal perforation may produce minimal abdominal signs in the early stages, so clinical deterioration or persistent pain requires active investigation and escalation.
Recognition and initial management
Any patient with abdominal pain following ERCP requires close observation and prompt assessment. Investigations should include:
- lipase
- liver function tests
- full blood examination
- urea, electrolytes and renal function
- C-reactive protein.
CT imaging, preferably with oral contrast, where perforation is suspected.
If perforation is suspected or confirmed, the patient should be admitted and an early senior surgical opinion obtained, including liaison with a hepatopancreatobiliary surgeon where available. Nasogastric decompression and intravenous antibiotics should be commenced, with close clinical observation and timely reassessment.
Management according to perforation type
- Guidewire perforation: can usually be managed conservatively with close monitoring.
- Duodenal perforation: requires repair. Endoscopic clip closure may be appropriate when the injury is identified during ERCP; otherwise, operative repair is required.
- Ampullary perforation: may be managed conservatively in selected patients but may require repeat ERCP with placement of a covered metallic stent and/or drainage of retroperitoneal collections.
Any deterioration requires urgent recognition, senior review and escalation of treatment.
Recommendations
The Surgical Subcommittee (SSC) of the Victorian Perioperative Consultative Council (VPCC) strongly recommends that clinicians and health services:
- consider duodenal or other gastrointestinal perforation, as well as pancreatitis, in any patient who develops abdominal pain following ERCP
- closely observe patients with post-ERCP pain and promptly undertake appropriate laboratory investigations and CT imaging, preferably with oral contrast, when perforation is suspected
- ensure early senior surgical review and liaison with a hepatopancreatobiliary surgeon when perforation is suspected or confirmed
- commence appropriate initial management, including admission, nasogastric decompression, intravenous antibiotics and frequent clinical reassessment
- manage treatment according to the site and mechanism of perforation, with timely endoscopic, radiological or operative intervention as clinically indicated
- escalate care urgently if the patient deteriorates or fails to improve.
- report ERCP-related perforations to the Victorian Perioperative Consultative Council through Safer Care Victoria, including cases that do not meet Sentinel Event criteria, to improve visibility of these events, identify recurring risks and system-level themes, and support statewide learning and targeted safety improvements.
References
Boonstra K, Voermans RP and van Wanrooij RLJ (2024) ‘Management of iatrogenic perforations during endoscopic interventions in the hepato-pancreatico-biliary tract’, Best Practice & Research Clinical Gastroenterology, 70:101890.
Langerth A, Isaksson B, Karlson B-M, Urdzik J and Linder S (2020) ‘ERCP-related perforations: a population-based study of incidence, mortality, and risk factors’, Surgical Endoscopy, 34(5):1939–1947.
Tringali A and Costamagna G (2025) ‘Post-ERCP perforation’, UpToDate, accessed 5 November 2026.