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event (AE) that may follow endoscopic retrograde cholangiopancreatography (ERCP). Fortunately, it is also the only AE for which significant advances have been made. Since 2010, four scientific societies have issued guidelines about the prophylaxis of post-ERCP pancreatitis (PEP). All of them have recommended rectal nonsteroidal anti-inflammatory drugs (NSAIDs) as the cornerstone of pharmacological prophylaxis of PEP (▶Table 1). This has led to slow adoption in the community: In 10 years, the proportion of endoscopists who use rectal NSAIDs for PEP prophylaxis has increased from 15% to 54% to 98% [1–4]. The latest survey reported use of rectal NSAIDs by 98% of pancreaticobiliary endoscopists but by only 40% of them in average-risk patients [4]. This is despite the demonstration of NSAID efficacy in this risk category of patients by 11 of 14 meta-analyses published to date [5]. Reasons accounting for this slow and incomplete adoption include disbelief and confusion because scientific societies recommend NSAIDs in different risk categories of patients (▶Table1). Surprisingly, cost could become another reason: a single NSAID suppository costs $ 347 in the United States, and it is billed between $50 and $5000 to ambulatory patients by Californian hospitals [6]. Therefore, exploration for alternatives that might be even more widely available, easy to use, innocuous, and cheap than NSAIDs is welcome. In the current issue of Endoscopy International Open, a meta-analysis suggests that spraying epinephrine onto the papilla is effective to prevent PEP [7]. Overall, the meta-analysis found no significant difference between PEP rates in patients Should we incorporate topical epinephrine in the ESGE guideline on prevention of post-ERCP pancreatitis?