Endoscopic retrograde cholangiopancreatography (ERCP) has become a standard procedure for the management of numerous pancreato-biliary diseases since the first report of successful biliary cannulation in 1968 [1]. Whereas diagnostic ERCP has been completely replaced by non-invasive diagnostic modalities such as magnetic resonance cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS), therapeutic ERCP is performed worldwide, in various settings ranging from non-academic to high-volume, academic referral centers, and reaching 200000 cases performed annually in the USA [2]. Previous publications have shown that although highly effective and having replaced prior surgical management for many indications [2], ERCP still has a higher complication rate compared to other commonly performed endoscopic procedures [[3], [4], [5]].

Understanding the incidence, underlying mechanism of ERCP-related complications, and related risk factors as well as applying established methods of prevention is crucial for all endoscopists performing ERCP, as well as health care providers involved in patient care. Indeed, reviewing all potential complications with the patient, as well as the preventive strategies undertaken, consists the backbone of obtaining informed consent before the procedure [6].

Post-ERCP acute pancreatitis (PEP) is the most frequent complication and despite the improvement of endoscopic techniques, PEP rate remains stable through time [4]. The incorporation of the incidence of PEP as a performance measure from both the European (ESGE) and American Societies of Gastrointestinal Endoscopy (ASGE) highlights even more the importance of optimal prevention [[7], [8], [9]].

The present work offers a comprehensive overview of ERCP-related complications, including underlying mechanisms, risk factors and preventive strategies (Fig. 1).