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Background With an overall incidence of 3.5%, pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography ( ERCP). Periprocedural hydration may prevent post- ERCP pancreatitis by maintaining pancreatic microperfusion, thereby inhibiting the pancreatic inflammatory response. However, the evidence for periprocedural hydration as a preventive measure is unclear. Aim To conduct a systematic review to assess the evidence regarding periprocedural hydration as a preventive measure for post- ERCP pancreatitis. Methods We searched PubMed and EMBASE databases and adhered to the PRISMA guidelines. We included studies addressing periprocedural hydration as a preventive measure to reduce frequency and severity of post- ERCP pancreatitis. Study quality was assessed by using the MINORS and Cochrane Collaboration's tool. Results Six studies with a total of 1102 patients were included. Two randomised controlled trials reported a decreased incidence of post- ERCP pancreatitis after hydration: 0% vs. 17% ( P = 0.016) and 5.3% vs. 22.7% ( P = 0.002). A third trial and two case-controls studies did not report significant differences. Two retrospective studies found that patients with mild post- ERCP pancreatitis had received significantly more fluids during (mean 940 mL vs. 810 mL; P = 0.031) or after ERCP (median 2834 mL vs. 2044 mL; P < 0.02) compared to patients with moderate/severe disease. Adverse events of periprocedural hydration were not reported in any of the included studies. The different methodologies of the included studies precluded a formal data synthesis. Conclusions There is some evidence to suggest that hydration affords protection against post- ERCP pancreatitis, but study heterogeneity precludes firm conclusions. Adequately powered randomised trials are needed to evaluate the preventive effect of periprocedural hydration. [ABSTRACT FROM AUTHOR]