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
3 abstracts
included
5 RCT 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
CO2
AIR
Sex(female)
CO2
AIR
54+18
Brettheur etal
58
58
57+16
Dellon etal
36
38
Lugiano etal
37
39
Maple etal
50
50
kutawani etal
40
40
Arjunan etal
147
151
sweelinchen etal
34
27
Bhalme etal
60
60
CO2
CO2 DELIVERY
AIR
72%
62% OLYMPUS ECR
60.1+15 59.7+16.6
47%
50% OLYMPUS ECR
66.1+14.6 67.1+16.4
59%
53% E Z EM inc
57
51.7
66.1+9.8 68.7+10.9
58.4
52%
37%
50%
40%
E Z EM INC
OLYMPUS ECR
PROCEDURE TIME
CO2
AIR
43+27
48+25
39.3
35.1
34.1+17.8 37.3+17.6
31.1
31.6
45+24.75 43+22.4
58.4
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
CO2
Pain scale
AIR
VAS 10 point
pre procedure Not significant
Brettheur
CO2
Lugiano
Sweelinchen
AIR
CO2 AIR
CO2
VAS 100 mm
VAS 100mm
VAS 10 point
AIR
Dellon
CO2
Arjunan
AIR
VAS 100mm
CO2
AIR
VAS 1-10cm
Maple
CO2
Bhalme
AIR
VAS 10 point
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
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
7
21 8+2.5 28.1+9.6
20.8+32.2 22.3+27.8
28% 48%
6 hours
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
1 hour
3 hours
1.4+2 0.9+2
CO2
AIR
VAS 10 point
0% 10%
 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
SCALE
Kutawani
Breetheur
Lugiano
Dellon
Arjunan
Maple
GVS-Xray
Xray
VAS100mm
abd girth-cm
Abd girth cm
Abd girth-cm
CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 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
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
Rate of increase
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
Type of sedation
Kutawani
Breetheur
Dellon
Bhalme
Lugiano Sweelin Maple
CO2
AIR
CO2
AIR
CO2
AIR
CO2
AIR
fentanyl,midazolam Midazolam,pethidineFentanyl,midazolam Fentanyl,midazolam Propofol Propofol Propofol
Fentanyl (mcg)
115+48.9 130+53.5
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
Diazepam (mg)
2+0.8
2+0
Scopolamine
ine(mg) 23+6.6
1.2+0.4
6.4+2.8
162.2
75
75
9.1
10.7
4
4.5
17
25
0.5
0.3
20.6+2.4
Promethazine
zine(mg)
Glucagon (mg)
6.3+3.6
155.6
1.1+0.2
 No significant difference in dose of sedation
used between 2 groups
 No significant difference in dose of
antispastic drugs used.
SAFET Y OF CARBON DIOXIDE
INSUFFLATION
Co2 monitoring
Baseline
Post procedure
Maximum CO2
Kutawani
Brettheur
Lugiano
Dellon
Arjunan
Maple Bhalme
SPO2
SPCO2
PETCO2
SPCO2
PETCO2
SPO2 SPO2
CO2 AIR CO2 AIR CO2 AIR CO2 AIR CO2 AIR
97.8+1.3 97.7+1.3 NS NS 29.8+1.8 30+1.6 40.5 40.3
97.1+1.4 96.6+1.3 NS
NS
32.6+2.6 30.7+1.3
46.1 45.2 NS
32.6+2.6 30.7+1.3
50 48.7
NS
 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.