A prospective randomised controlled trial comparing carbon dioxide and air insufflation during ERCP: Is it worth the pain?

Abstract

Background: Carbon dioxide (CO 2 ) insufflation has been shown to reduce post-procedural pain in endoscopic procedures such as flexible sigmoidoscopy and colonoscopy due to improved absorption via the gastrointestinal tract and subsequent reduction in bowel distension. The benefit of CO 2 insufflation in upper endoscopic procedures including endoscopic retrograde cholangiopancreatography (ERCP) is less clear.Aim: To evaluate the efficacy and safety of carbon dioxide insufflation in ERCP. Methods:We conducted a prospective randomised controlled trial of patients requiring ERCP at Lyell McEwin Hospital (Adelaide, Australia) between 2011 and 2013. Patients were randomised to air insufflation or CO 2 . Post-procedural pain, abdominal distension, nausea, capnography and adverse events were recorded on arrival to the recovery room, 1 hour post-recovery, on discharge and 24 hours postdischarge. Baseline characteristics of each study group were compared with Student's t tests for quantitative variables and a chi-squared test for qualitative variables. Results were deemed statistically significant when the P value was <0.05. Results:A total of 94 patients were randomised in this trial. There were no significant differences in abdominal distension, nausea, capnography, amount of sedation used and adverse events noted at any time point after ERCP was performed.Patients in the air group experienced significantly more abdominal pain in comparison to the CO 2 arm (2.0 vs 0.9; P = 0.027) 1 hour after the procedure. No significant difference in post-procedural pain was noted at the other time points.Conclusion: Although safe to use in ERCP, CO 2 insufflation appears to have little to no benefit over standard air insufflation alone.

Clinical Presentation, Diagnosis, and Management of Air Embolism During Endoscopic Retrograde Cholangiopancreatography

“…Kwan and colleagues used CO 2 instead of air, which reduced the risk of embolism as CO 2 is absorbed more easily. It is also associated with less pain after the procedure and less abdominal distension [50]. The presence of congenital right-to-left shunt should be ruled out in all patients considered for ERCP, possibly via echocardiography before the procedure [5].…”