Introduction Post-ERCP acute pancreatitis (post-ERCP-AP) occurs in ∼5% of patients undergoing ERCP, severe in ∼1%. Despite multiple trials, optimal prophylaxis remains undetermined. We sought to clarify the effectiveness of prophylactic interventions for post-ERCP AP through multiple meta-analyses of randomised controlled trials (RCTs).

Methods MEDLINE, EMBASE and the Cochrane Library were searched by two independent reviewers to identify all RCTs that tested treatments to reduce post-ERCP AP. Data were extracted to permit Jadad scoring, grouping of RCTs by therapeutic mechanism and separate meta-analysis of each group. The main outcome measure was post-ERCP AP, defined as amylase elevated to >3× upper limit of normal with >24 h abdominal pain.

Results 71 RCTs of the highest quality (Jadad score 5 for pharmacological and three for interventional trials) were identified. Pancreatic stents (trials (T)—5; patients (P)—377; RR 0.20; 95% CI 0.09 to 0.42) were most effective; significant reductions in post-ERCP AP resulted from secretion inhibitors (T—12; P—4851; RR 0.54; CI 0.36 to 0.83), protease inhibitors (T—9; P—3752; RR 0.54; CI 0.38 to 0.78) and smooth muscle relaxants (T—9; P—2110; RR 0.67; CI 0.52 to 0.87). Non-steroidal anti-inflammatory drugs (NSAIDs; T—4; P—733; RR 0.68; CI 0.46 to 1.00), interleukin-10 (IL-10; T—3; P—642; RR 0.79; CI 0.55 to 1.14), anti-oxidants (T—5; P—2100; RR 0.90; CI 0.54 to 1.50), anti-coagulants (T—2; P—533; RR 0.85; CI 0.48 to 1.53), non-ionic (vs ionic) contrast agents (T—8; P—3095; RR 1.32; CI 0.92 to 1.88), wire guided cannulation, (T—7; P—2103; RR 0.63; CI 0.34 to 1.17) pre cut papillotomy (T—4; P—558; RR 0.57; CI 0.20 to 1.59) and steroids (T—3; P—924; RR 1.09; CI 0.70 to 1.70) did not reduce post-ERCP AP.

Conclusion This is the most comprehensive systematic review on the subject to date which shows that pancreatic stents, secretion and protease inhibitors and smooth muscle relaxants reduce the risk of post-ERCP AP. Large well-designed RCTs of combination vs single agent prophylaxis are required.

Competing interests None declared.