Post-Endoscopic Retrograde Cholangiopancreatography Pancreatitis in the Oldest Old: Balancing Pancreatic Protection and Cardiorenal Safety: A Narrative Review.

As the global population ages, the demand for endoscopic retrograde cholangiopancreatography (ERCP) in the "oldest old" (≥ 85 years) is steadily increasing. Despite their vulnerability, the existing evidence base for prophylaxis is heavily derived from younger populations, creating a significant extrapolation gap. Current guidelines for the prevention of Post-ERCP pancreatitis (PEP) advocate for universal measures-such as aggressive hydration and rectal nonsteroidal anti-inflammatory drugs-based on trials that frequently exclude frail patients with significant comorbidities. This perspective piece challenges the "one-size-fits-all" application of these protocols in the geriatric demographic, proposing a hypothetical clinical practice approach. We conducted a targeted review of peer-reviewed literature focusing on the pathophysiology of the aging pancreas and the safety of prophylactic interventions. Key findings reveal a "risk-outcome dissociation": while pancreatic senescence biologically lowers PEP incidence, frailty increases mortality when it occurs. Regarding fluid management, we propose a hypothesis-driven, restrictive hydration rate of 1.7 mL/kg/h without a bolus for patients with heart failure. This rate is physiologically grounded (adapted from the Holliday-Segar pediatric maintenance formula for the altered body composition of the elderly) to provide "enhanced maintenance" to cover fasting deficits while avoiding the volume surge (≥ 3 mL/kg/h) that precipitates pulmonary edema in non-compliant ventricles. Treating the elderly requires a paradigm shift to "Precision Geriatric Endoscopy", utilizing biomarker-driven triage and bedside frailty tools. Most critically, this proposed protocol represents a pathophysiological hypothesis and framework rather than established evidence. Future prospective randomized controlled trials are urgently needed to validate this approach.