Prevention and treatment of post‐endoscopic retrograde cholangiopancreatography cholangitis: Current evidence and future directions

Abstract Background Cholangitis represents a common infectious sequela of endoscopic retrograde cholangiopancreatography (ERCP), occurring in 0.5%–3% of procedures, and may deteriorate into severe cholangitis and sepsis. Methods This narrative review synthesises contemporary evidence on the prevention and management of post‐ERCP cholangitis. The literature search followed applicable Systematic Reviews and Meta‐Analyses (PRISMA) 2020 items for narrative reviews. PubMed, Web of Science, Embase, Cochrane Library, China National Knowledge Infrastructure (CNKI), and Wanfang Data were searched from January 2015 to May 2026. Results The principal mechanisms involve retrograde bacterial contamination and compromised bile drainage. Preventive measures should be individualised according to preoperative cholangitis status: in patients with pre‐existing cholangitis, therapeutic antibiotics plus urgent drainage are critical; in those without, postoperative prevention is key. Prevention encompasses strict ERCP indications, early risk assessment, selective prophylactic antibiotics, meticulous intraoperative technique, and postoperative monitoring. Treatment requires prompt empirical antibiotics covering Gram‐negative bacilli and anaerobes, followed by susceptibility‐guided adjustment, together with early biliary drainage. Endoscopic drainage is preferred; percutaneous transhepatic and endoscopic ultrasound (EUS)‐guided drainage are second‐line options, and surgery is reserved as a last resort. Key recommendations were graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Prophylactic antibiotic biliary lavage and novel biliary stents remain controversial. Conclusion Improved outcomes depend on early risk assessment, adequate biliary drainage, and prudent antimicrobial use. Strategies should be individualised by preoperative cholangitis status. Large‐scale, multicentre randomised controlled trials are needed to refine personalised management.