Background and Objectives: Aspiration pneumonia is a well-described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post-endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP). Materials and Methods: All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between 1 April 2022 and 31 August 2024 were retrospectively evaluated. Demographic, clinical and endoscopic data were collected. Results: One thousand one hundred forty consecutive ERCPs were included. The main indication was malignant biliary stricture, and the patient’s mean age was 68 ± 13.9 years. Overall incidence of pEP was 2.7%. The American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated with a higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-day mortality and for prolonged hospital stay. Conclusions: pEP is a relatively frequent adverse event after ERCP. In patients with a high ASA-score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.