The use of carbon dioxide for insufflation during GI endoscopy: a systematic review

Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography reduces bowel gas volume but does not affect visual analogue scale scores of suffering: a prospective, double-blind, randomized, controlled trial

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) and related procedures can cause abdominal pain and discomfort. Two clinical trials have indicated, using the visual analogue scale (VAS) score, that CO(2) insufflation during ERCP ameliorates the suffering of patients without complications, compared with air insufflation. However, differences in patient suffering between CO(2) and air insufflation after ERCP under deep conscious sedation have not been reported. We focused on the gas volume score (GVS) as an objective indicator of gas volume, and designed a multicenter, prospective, double-blind, randomized, controlled study with CO(2) and air insufflation during ERCP.

METHODS

Between March 2010 and August 2010, 80 patients who required ERCP were enrolled and evenly randomized to receive CO(2) insufflation (CO(2) group) or air insufflation (air group). ERCP and related procedures were performed under deep conscious sedation with fentanyl citrate or pethidine and midazolam or diazepam. The GVS was evaluated as the primary endpoint in addition to the VAS score as the secondary endpoint.

RESULTS

The GVS after ERCP and related procedures in the CO(2) group was significantly lower than that in the air group (0.14 ± 0.06 vs. 0.31 ± 0.11, P < 0.01), as well as the rate of increase in GVS ([GVS after - GVS before]/[GVS before ERCP and related procedures] × 100) (3.8 ± 5.9 vs. 21 ± 11.1%, P < 0.01). VAS scores 3 and 24 h after ERCP and related procedures were comparable between the CO(2) and air groups for abdominal pain, abdominal distension, and nausea. Additionally, VAS scores were not correlated with the GVS.

CONCLUSIONS

CO(2) insufflation during ERCP reduces GVS (bowel gas volume) but not the VAS score of suffering compared with air insufflation. Deep and sufficient sedation during ERCP and related procedures is important for the palliation of patients' pain and discomfort.

Carbon dioxide insufflation for colonoscopy: evaluation of gas volume, abdominal pain, examination time and transcutaneous partial CO2 pressure

BACKGROUND

Insufflation with carbon dioxide (CO(2)) in colonoscopy has not been widely adopted and, consequently, limited data are available on insufflated gas volume and blood pCO(2). The aim of this study was to compare CO(2) and air as an insufflation agent in patients undergoing colonoscopy without sedation in terms of insufflated gas volume, pCO(2), pain and examination time.

METHODS

This was a randomized, double-blind, control trial. Consecutive patients presenting for colonoscopy, excluding those with lung or malignant disease, were randomized into two groups: insufflation with air or with CO(2), respectively. Insufflated gas volume, pain, pCO(2) and examination time were assessed.

RESULTS

The study cohort comprised 120 patients (66 randomized to CO(2) group). No significant difference in insufflated gas volumes was found between the CO(2) and air groups. The mean pCO(2) measured before, during (the peak value) and 30 min after colonoscopy were 40, 43 and 40 mmHg, respectively, in both groups. The pain scores in the air group were significantly greater than those in the CO(2) group until 3 h after the examination. There was a significant faster cecal intubation time and a trend toward shorter examination time in the CO(2) group.

CONCLUSIONS

The CO(2) gas volume used in our study (14.0 L) was much greater than that reported by others (8.3 L), but the pCO(2) values were still within the normal reference range, indicating the safety of CO(2) insufflation over a greater range of CO(2) gas volume. Among our patients, CO(2) insufflation was associated with relatively less pain and a shorter examination time. Based on our results, we recommend that CO(2) become the standard gas for insufflation in patients undergoing colonoscopy without sedation.

[A case of synchronous colonic laterally spreading tumors treated by sequential endoscopic submucosal dissection performed on two consecutive days]

Endoscopic submucosal dissection (ESD) is an useful therapeutic technique for large gastrointestinal epithelial tumors that it provides an en bloc resection. Although there is some controversy about the role of ESD for colorectal lesions, for large lesions in the distal rectum, ESD has the advantage of preserving anal function. However, the large amount of insufflating gas used during the procedure can cause severe abdominal pain and discomfort. Moreover, high intra-luminal pressure caused by a by large amount of gas can cause a micro-perforation. There is no consensus as to whether ESD is the optimal treatment for synchronous large colorectal laterally spreading tumors (LSTs) that cannot be removed en-bloc by conventional endoscopic mucosal resection. Here, a case with two neighboring synchronous large LSTs, one located in the rectum and the other in the distal sigmoid colon, were sequentially removed by separate ESD procedures performed on two consecutive days in a patient who could not tolerate a long procedure.

A randomized, controlled, double-blind trial of air insufflation versus carbon dioxide insufflation during ERCP

BACKGROUND

Visualization during GI endoscopy requires distention of the bowel lumen. Carbon dioxide (CO(2)) insufflation decreases postprocedure abdominal discomfort and distension after colonoscopy, but there have been few published studies on its use in ERCP.

OBJECTIVE

To assess the safety and efficacy of CO(2) insufflation during ERCP.

DESIGN

Double-blind, controlled, randomized trial.

SETTING

Tertiary-care referral center.

PATIENTS

This study involved consecutive patients referred for ERCP, excluding those with known CO(2) retention or with chronic use of opiate medications.

INTERVENTION

Insufflation of CO(2) versus insufflation of air.

MAIN OUTCOME MEASUREMENTS

Primary outcomes were abdominal pain assessed on a visual analogue scale and abdominal distension. Secondary outcomes included transcutaneous CO(2) levels (pCO(2)) and procedural complications.

RESULTS

We analyzed 74 patients, 38 in the air group and 36 in the CO(2) group. Pain scores were similar in both groups 1-hour postprocedure (16 vs 11 mm in the CO(2) and air groups, respectively; P = .29) as well as over the subsequent 24 hours. There were also no significant differences between groups in abdominal distension or pCO(2) levels. There were 13 patients with complications in the air group and 5 in the CO(2) group (P = .04; nominal significance removed by Bonferroni correction), although most complications were minor in nature.

LIMITATIONS

Single-center study.

CONCLUSION

The use of CO(2) for insufflation during ERCP was safe in a tertiary-care referral population. However, use of CO(2) during ERCP did not lead to decreased postprocedural pain or less abdominal distension, so its role in this procedure remains in question. NCT00685386.

Carbon dioxide insufflation is useful for obtaining clear images of the bile duct during peroral cholangioscopy (with video)

BACKGROUND

Peroral cholangioscopy (POCS) is useful for the diagnosis of various bile duct lesions. However, it is often difficult to obtain clear images because of bile or biliary sludge in the bile duct, even after vigorous irrigation of the bile duct with saline solution. Therefore, this study investigated whether inflation with carbon dioxide (CO(2)) yields clearer images of the bile duct than conventional saline solution irrigation during POCS.

OBJECTIVE

To evaluate the clinical utility and safety of CO(2) insufflation into the bile duct to obtain clear images in POCS observations by comparing this method with conventional saline solution irrigation.

SETTING

A single center.

DESIGN

Case-control study.

PATIENTS

Nineteen patients with suspected biliary diseases.

INTERVENTIONS

CO(2) insufflation into the bile duct during POCS.

MAIN OUTCOME MEASUREMENTS

The quality and safety of this method.

RESULT

The quality of the images of the bile duct lumen with CO(2) insufflation (10 patients) was significantly superior to those with saline solution irrigation (9 patients) in both clarity (P < .05) and color (P < .05). In particular, extremely clear images could be obtained from the middle part of common bile duct to the right and left hepatic duct. No serious POCS-related complications occurred. There was no significant change in the venous partial pressure of the CO(2) level during the procedure.

LIMITATIONS

The number of patients examined was small.

CONCLUSIONS

CO(2) insufflation is useful for obtaining clear images of the bile duct during POCS, which makes it possible to determine the qualitative diagnosis and the extent of various bile duct lesions.