["Geriatrics &Gerontology International, Volume 26, Issue 5, May 2026. ", "\nWhile the aging pancreas reduces post‐ERCP pancreatitis incidence, frailty amplifies mortality when it occurs. For the oldest old (≥ 85 years), we propose “Precision Geriatric Endoscopy”—a tailored protocol integrating frailty assessment, BNP‐guided restrictive hydration, and individualized NSAIDs—to balance pancreatic protection with cardiorenal safety.\n\nABSTRACT\nAs 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.\n"]