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Background  Cholangiocarcinoma (CCA) is a fatal bile duct cancer associated with infection by the liver fluke,  Opisthorchis viverrini , in the lower Mekong region. Numerous public health interventions have focused on reducing exposure to  O. viverrini , but incidence of CCA in the region remains high. While this may indicate the inefficacy of public health interventions due to complex social and cultural factors, it may further indicate other risk factors or interactions with the parasite are important in pathogenesis of CCA. This systematic review aims to provide a comprehensive analysis of described risk factors for CCA in addition to  O. viverrini  to guide future integrative interventions.    Main body  We searched five international and seven Thai research databases to identify studies relevant to risk factors for CCA in the lower Mekong region. Selected studies were assessed for risk of bias and quality in terms of study design, population, CCA diagnostic methods, and statistical methods. The final 18 included studies reported numerous risk factors which were grouped into behaviors, socioeconomics, diet, genetics, gender, immune response, other infections, and treatment for  O. viverrini . Seventeen risk factors were reported by two or more studies and were assessed with random effects models during meta-analysis. This meta-analysis indicates that the combination of alcohol and smoking ( OR  = 11.1, 95%  CI : 5.63–21.92,  P  <  0.0001) is most significantly associated with increased risk for CCA and is an even greater risk factor than  O. viverrini  exposure. This analysis also suggests that family history of cancer, consumption of raw cyprinoid fish, consumption of high nitrate foods, and praziquantel treatment are associated with significantly increased risk. These risk factors may have complex relationships with the host, parasite, or pathogenesis of CCA, and many of these risk factors were found to interact with each other in one or more studies.    Conclusions  Our findings suggest that a complex variety of risk factors in addition to  O. viverrini  infection should be addressed in future public health interventions to reduce CCA in affected regions. In particular, smoking and alcohol use, dietary patterns, and socioeconomic factors should be considered when developing intervention programs to reduce CCA.    Electronic supplementary material  The online version of this article (10.1186/s40249-018-0434-3) contains supplementary material, which is available to authorized users.

Thinking beyond Opisthorchis viverrini for risk of cholangiocarcinoma in the lower Mekong region: a systematic review and meta-analysis