Carbon dioxide insufflation in ERCP.

CARBON DIOXIDE
INSUFFLATION IN ERCP
:A SYSTEMATIC REVIEW
Dr.Samji
Dr.Komanapalli
Dr.Roy
Marshfield clinic, Wisconsin.

INTRODUCTION
• ERCP is a valuable technique used as a
diagnostic and therapeutic option for many
pancreatic and biliary pathologies.
• Air insufflation is used for insufflation of
duodenum.
• Abdominal pain and nausea are the non
specific complaints of ERCP

• Carbon dioxide is easily absorbed and
excreted compared to air.
• So carbon dioxide was thought to decrease
abdominal distension there by decrease
abdominal pain.

AIMS OF THE STUDY
• To compare the effect of carbon dioxide to
air insufflation in ERCP.
• To assess the safety of carbon dioxide
insufflation in ERCP.

OUTCOMES
• Post procedural abdominal pain
• Post procedural abdominal distension
• Dose of sedation
• Safety of carbon dioxide insufflation.

SEARCH STRATEGY
• PubMed, Medline, Cochrane database and recent
abstracts from major conference proceedings were
searched.
• RCT’s comparing role of CO2 and air insufflation in
ERCP were included.
• Standard forms were used to extract data by two
independent reviewers.
• We included all the studies that compared CO2 to Air
insufflation in ERCP through 7/2012.

2625 Publications
2620 excluded
5 RCT included
3 abstracts
included
2 RCT 1 Retrospective

GENERAL DESCRIPTION OF STUDIES
• 8 studies were included in our systematic review.7
studies are randomized double blinded control trials and
1 study is retrospective study.
• Total number of 925 patients are included in 8 studies.
• No significant difference in patient population noted.

INCLUSION CRITERIA
• Adult pts. requiring ERCP.

EXCLUSION CRITERIA
• No consent
• Age < 20 years
• Significant pre procedural abdominal pain
• Patients with COPD.
• Pregnant patients
• Chronic use of narcotics-long acting opioid daily more
than 45 days.
• Acute pancreatitis
• Poor health status.
• One study included patients with COPD without CO2 retention
or requiring oxygen, CAD,OSA.(Dellon etal)

GENERAL CHARECTERISTICS
NAME OF STUDY Number of patients AGE Sex(female) CO2 DELIVERY PROCEDURE TIME
CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR
Brettheur etal 58 58 57+16 54+18 72% 62% OLYMPUS ECR 43+27 48+25
Dellon etal 36 38 60.1+15 59.7+16.6 47% 50% OLYMPUS ECR 39.3 35.1
Lugiano etal 37 39 66.1+14.6 67.1+16.4 59% 53% E Z EM inc 34.1+17.8 37.3+17.6
Maple etal 50 50 57 51.7 52% 50% E Z EM INC 31.1 31.6
kutawani etal 40 40 66.1+9.8 68.7+10.9 37% 40% OLYMPUS ECR 45+24.75 43+22.4
Arjunan etal 147 151
sweelinchen etal 34 27 58.4 58.4
Bhalme etal 60 60 29 33

EFFECT ON POST PROCEDURAL
ABDOMINAL PAIN
• Abdominal pain was measured by different scales
and at different point of times.
• No significant difference in pre procedural
abdominal pain .

Kutawani Brettheur Lugiano Sweelinchen Dellon Arjunan
Maple
Bhalme
CO 2 AIR CO 2 AIR CO2 AIR CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR
Pain scale
VAS 10 point VAS 100 mm VAS 100mm VAS 10 point VAS 100mm VAS 1-10cm VAS 10 point
VAS 10 point
pre procedure
Not significant
15 15 5.7+5.4 6.2+6.7 0.38 1.51 12.8+19.6 10.5+21.0 Not significant 0.5 0.48
1 hour
5 19 10+4.4 35+12 0.38 0.37 16.4+25.2 10.8+19.3 0.61+0.67 0.84+0.95 0.7 1.9 0% 10%
3 hours
6 hours
1.4+2 0.9+2 7 21 8+2.5 28.1+9.6 20.8+32.2 22.3+27.8 28% 48%
10 22 7+2.5 14.1+4.7 18.3+25.4 19.5+26.7 28% 48%
24 hours
1.1+1.9 0.5+1.3 4 20 4.2+3.4 5+2.8 15.0+24.7 15.5+24.0
Not significant

• Post procedural abdominal pain was less in
carbon dioxide group till 6 hours after
procedure.
• There was no significant difference between 2
groups 24 hours after procedure.

EFFECT ON POST PROCEDURAL ABDOMINAL
DISTENSION
Kutawani Breetheur Lugiano Dellon Arjunan Maple
SCALE GVS-Xray Xray VAS100mm abd girth-cm Abd girth cm Abd girth-cm
CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR
Pre procedure
0.11+0.04 0.10+0.05 4.2+3.4 4.5+3.7 101.5+15 105.5+16
Post procedure
Rate of increase
0.14+0.06 0.31+0.11 13% 29% 8.8+5.3 31.7+19.2 102.2+14 106.2+17.4
3.8+5.9 21.0+11.1 0.7+3.8 0.8+4.8 0.69+1.12 1.02+1.32 0.3 2.1

• 4 out of 6 studies noticed significant decrease
in abdominal distension in CO2 group compared
to air group.
• 1 study noticed that 29% patients in air group
had moderate to severe distension compared to
13% in CO2 group.

EFFECT ON DOSE OF SEDATION
Kutawani Breetheur Dellon Bhalme Lugiano Sweelin Maple
CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR
Type of sedation fentanyl,midazolam Midazolam,pethidineFentanyl,midazolam Fentanyl,midazolam Propofol Propofol Propofol
Fentanyl (mcg) 115+48.9 130+53.5 155.6 162.2 75 75
Pethidine (mg) 54.4+24.5 38.5+11.1 35.2+27.9 44.0+37.3
Midazolam(mg) 7.3+3.6 8.4+3.7 6.3+3.6 6.4+2.8 9.1 10.7 4 4.5
Diazepam (mg) 2+0.8 2+0
Scopolamine ine(mg) 23+6.6 20.6+2.4
Promethazine zine(mg) 17 25
Glucagon (mg) 1.2+0.4 1.1+0.2 0.5 0.3

• No significant difference in dose of sedation
used between 2 groups
• No significant difference in dose of
antispastic drugs used.

SAFETY OF CARBON DIOXIDE
INSUFFLATION
Kutawani Brettheur Lugiano Dellon Arjunan Maple Bhalme
Co2 monitoring SPO 2 SPCO 2 PETCO 2 SPCO 2 PETCO 2 SPO2 SPO2
CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR CO 2 AIR
Baseline 97.8+1.3 97.7+1.3 NS NS 29.8+1.8 30+1.6 40.5 40.3
Post procedure
97.1+1.4 96.6+1.3 NS NS 32.6+2.6 30.7+1.3 46.1 45.2 NS NS
Maximum CO 2
32.6+2.6 30.7+1.3 50 48.7

• No significant respiratory depression or
respiratory complications noted with CO2
insufflation.
• No significant adverse events or complications
noted in CO2 group compared to air group.

CONCLUSIONS
• Carbon dioxide insufflation in ERCP can reduce post
procedural abdominal pain and the effect lasts till 6
hours after procedure.
• Abdominal distension was less in carbon dioxide group
compared to air group.
• There was no significant difference in dose of sedation
and dose of antispastic drugs used.

• Carbon dioxide insufflation is found to be safe in
ERCP
• Safety still needs to be established in patients
with COPD, obstructive sleep apnea, morbid
obesity, patients who has multiple co morbid
conditions and medically unstable patients.