Prevention of Post-ERCP Pancreatitis: Current Strategies

Abstract Post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) remains the most common and feared adverse event associated with ERCP, contributing substantially to procedure-related morbidity, prolonged hospitalization, and health care costs. Despite advances in technique and patient selection, the incidence of PEP ranges from 3 to 10% in unselected populations and may exceed 15 to 20% in high-risk patients. Effective prevention requires a comprehensive understanding of patient-related, procedure-related, and operator-dependent risk factors, combined with evidence-based prophylactic strategies. This review provides a contemporary, evidence-based review of the prevention of PEP, integrating current guidelines and high-quality clinical trial data. We begin by outlining risk stratification, emphasizing established patient-related factors such as suspected sphincter of Oddi dysfunction, female sex, prior PEP, and normal bilirubin levels, as well as procedural variables including difficult cannulation, pancreatic duct injection, precut sphincterotomy, and pancreatic sphincterotomy. The importance of case selection and avoidance of unnecessary diagnostic ERCP in favor of noninvasive modalities such as endoscopic ultrasound and magnetic resonance cholangiopancreatography is underscored. Pharmacologic prophylaxis is reviewed in detail, with particular focus on rectal nonsteroidal anti-inflammatory drugs (NSAIDs), which represent the cornerstone of prevention. The timing, dosing, contraindications, and real-world implementation of rectal NSAIDs is discussed. Adjunctive measures, including aggressive periprocedural hydration with lactated Ringer's solution and the evolving role of sublingual nitrates, are critically appraised. Technical strategies including guidewire-assisted cannulation techniques, minimization of pancreatic duct contrast injection, early transition to precut when indicated, and the selective use of prophylactic pancreatic duct stenting in high-risk cases is subsequently discussed. Finally, we examine emerging preventive approaches and quality improvement initiatives aimed at reducing institutional PEP rates. This review provides a structured, multimodal approach to preventing PEP, ultimately enhancing procedural safety and improving patient outcomes in ERCP practice.