Systematic Review Open access Published: 04 November 2025 Ahmad Hormati, Asma Mousavi, Shayan Shojaei, Atie Moghtadaei, Sanaz Bordbar, Hediyeh Alemi, Amir Kasaeian & …Sadaf Sepanlou BMC Gastroenterology volume 25, Article number: 783 (2025) Cite this article AbstractEndoscopic retrograde cholangiopancreatography (ERCP) is a widely utilized procedure for diagnosing and treating biliary and pancreatic disorders. However, it carries a risk of post-ERCP pancreatitis (PEP). N-Acetylcysteine (NAC) has been proposed as a potential prophylactic agent due to its antioxidant properties, yet its efficacy remains debated. This systematic review and meta-analysis aimed to evaluate the effectiveness of NAC in preventing PEP in patients undergoing ERCP.We conducted a comprehensive literature search across multiple databases, including PubMed, Scopus, Web of Science, and EMBASE, for randomized controlled trials (RCTs) on humans published from January 2000 to end of August 2024. The primary outcome was the incidence of PEP in the group who received the NAC compared to the group receiving routine medication. Study selection and data extraction was performed according to PRISMA guidelines. Quality assessment was accomplished using risk of bias (RoB2) tool for RCTs.A total of four RCTs involving 773 patients were included in the final analysis. The meta-analysis demonstrated a non-significant lower incidence of post-ERCP pancreatitis in the NAC group compared to controls (Risk Ratio: 0.66; 95% Confidence Interval: 0.38–1.16). Sensitivity analyses indicated low robustness of these results, with moderate heterogeneity observed among studies (I2 = 55.89%). Egger test did not provide evidence of publication bias. The trim-and-fill correction suggested one potentially missing study on the left side of the funnel plot. Imputation for this potentially missing study yielded an effect size of RR: 0.57; 95% CI: 0.32—0.99), which was statistically significant this time. The results were additionally statistically non-significant stratified by severity of the PEP.While NAC shows promise in reducing the incidence of PEP, the current evidence does not support its routine use as a prophylactic agent. Further research is warranted to clarify its role and optimize preventive strategies for PEP.IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) is a medical procedure that combines endoscopy and fluoroscopy to diagnose and treat disorders of the bile ducts, pancreas, and gallbladder [1]. It is used for various purposes, including the management of gallstones, tumors, leaks, strictures, pancreatitis assessment, and therapeutic interventions such as stent placement. ERCP is indicated for investigating unexplained abdominal pain, suspected gallstones or strictures, and cases of pancreatitis or cancer [1].?
NAC N-acetyl cysteine
