Negative Endoscopic Retrograde Cholangiopancreatography: Incidence, Predictors, and Clinical Consequences-A Systematic Review and Meta-analysis.

Endoscopic retrograde cholangiopancreatography (ERCP) is widely used for the management of suspected biliary disease; however, a proportion of procedures yield no therapeutic findings, exposing patients to avoidable risks. This systematic review and meta-analysis evaluated the incidence, predictors, and clinical consequences of negative ERCP. A structured review was conducted in accordance with PRISMA 2020 principles, including studies of adult patients undergoing ERCP for suspected choledocholithiasis or biliary obstruction. Negative ERCP was defined as the absence of stones, sludge, or any therapeutic intervention. Across included studies, the incidence of negative ERCP ranged from 10 to 40%, with higher rates observed in intermediate-risk populations. Predictors included normalization of liver enzymes, lack of bile duct dilation, smaller or transient stones, and delays between presentation and intervention. Several studies have suggested that spontaneous stone passage is a key contributor. Importantly, negative ERCP was associated with clinically relevant complication rates, including post-ERCP pancreatitis, comparable to those observed in therapeutic procedures. These findings highlight limitations in current risk stratification and emphasize the need for confirmatory diagnostic strategies before ERCP. Reducing unnecessary ERCP has important implications for patient safety, healthcare utilization, and clinical outcomes.