内镜逆行胰胆管造影（ERCP）是一种常用的微创手术。接受 ERCP 的患者中发生空气栓塞的情况相对较少，约占所执行手术的 2-3%，而灾难性的空气栓塞则更为罕见。空气栓塞的症状可能来自心肺和神经系统。在 ERCP 并发症的鉴别诊断中记住这一点很重要，因为早期发现至关重要。在此处介绍的案例中，事故发生后立即进行的诊断性 CT 扫描让人们意识到空气栓塞的严重程度。 CT结果显示气泡进入上腔静脉和下腔静脉。胆管、十二指肠壁、心脏、股静脉和颅内都捕获了空气的存在。这种并发症的危险因素包括既往胆道手术、假体和支架的存在、胆管炎、肝脏肿瘤和肝胆瘘等解剖异常，以及肝内和肝外解剖漏。由于气体栓塞与严重的健康后果相关，了解该问题并做好充分的准备可能会减少该问题的发生。进行手术时应注意基本且容易采取的预防措施，例如患者的血流动力学状态、手术期间充足的水合作用和体位。

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly performed minimally invasive procedure. Air embolism in a patient undergoing ERCP is relatively rare, accounting for approximately 2-3% of procedures performed, and a catastrophic air embolism is even rarer. Symptoms of air embolism can come from the cardiopulmonary and nervous system. It is important to remember this in the differential diagnosis of complications of ERCP, as early detection is crucial. In the case presented here, the diagnostic CT scan performed immediately after the incident brings awareness of how massive an air embolism can be. The CT results showed gas bubbles entering both the superior and inferior vena cava. The presence of air has been captured in the bile ducts, duodenum wall, heart, femoral veins and intracranially. Risk factors for this complication include previous biliary surgeries, the presence of prostheses and stents, cholangitis, liver tumors and anatomical anomalies such as hepatobiliary fistulas, as well as intrahepatic and extrahepatic anatomical leaks. As gas embolism is associated with serious health consequences, knowledge of the problem and adequate preparation may reduce the occurrence of the problem. Attention should be paid to basic and easily obtainable precautions when performing the procedure, such as the patient's hemodynamic status, adequate hydration and positioning during the procedure.