The successful non-surgical management of retroduodenal perforation following endoscopic sphincterotomy is reported and the literature reviewed. Two patients are described who developed gas in the retroperitoneum following endoscopic sphincterotomy. One patient developed retroperitoneal emphysema and cervical emphysema, while the second patient developed retroperitoneal emphysema and a pneumothorax following endoscopic sphincterotomy. Both patients were treated conservatively and made uneventful recoveries. An algorithm for assessment and treatment is proposed based on the authors' experience and a literature review. Patients with confirmed ongoing duodenal leakage, sepsis or collection should have expeditious surgery.