Preventing Post-ERCP Pancreatitis: A Pragmatic Clinical Pathway from Periprocedural Prophylaxis to Early Postprocedural Triage

Post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) remains the most frequent and clinically relevant adverse event after ERCP. Although several preventive measures are supported by current evidence, their application in routine practice is often fragmented across the pre-procedural, intra-procedural, and post-procedural phases of care. As a result, patients with evolving risk may not receive timely escalation of prophylaxis or appropriately tailored post-procedural monitoring. This review provides a pragmatic clinical framework for integrating evidence-based PEP prevention with early post-ERCP risk stratification. We summarize baseline risk assessment before ERCP, distinguish routinely applicable preventive measures from strategies reserved for selected high-risk situations, and emphasize the importance of intra-procedural reassessment when procedural events such as difficult cannulation or unintended pancreatic duct manipulation increase risk in real time. We further discuss the role of early symptom assessment and post-procedural amylase/lipase measurement in supporting triage decisions, including selective observation, admission, or same-day discharge in appropriately selected patients. This integrated approach may improve consistency in routine ERCP care while highlighting important limitations related to generalizability, local resources, and implementation.