Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: a randomized, controlled, double-blind trial

Background and study aims: The effect on abdominal pain of using carbon dioxide (CO₂) for insufflation during endoscopic retrograde cholangiopancreatography (ERCP) has not been investigated. The present study aimed to compare CO₂ insufflation with standard air insufflation with respect to the pain experienced during and after ERCP. In addition, we investigated the effect of CO₂ insufflation on the partial pressure of CO₂ (Pco₂). Patients and methods: A total of 118 consecutive patients who were undergoing ERCP were randomized to CO₂ insufflation or to air insufflation during the procedure. Both the endoscopists and the patients were blinded with regard to the gas used. Patients rated the intensity of pain experienced on a 100-mm visual analogue scale (VAS) during ERCP and at 1 hour, 3 hours, 6 hours, and 24 hours after the procedure. Transdermal Pco₂ was measured continuously in all patients during the procedure. Results: Altogether, 116 patients were eligible for analysis, 58 in each treatment group, and 91 patients responded to the questionnaire (78 %). The mean severity of postprocedure pain was significantly reduced in the CO₂ group compared with the air group at 1 hour (5 mm vs. 19 mm on the VAS, P < 0.001), at 3 hours (7 mm vs. 21 mm, P < 0.001), at 6 hours (10 mm vs. 22 mm, P = 0.006), and at 24 hours (4 mm vs. 20 mm, P < 0.001) after the procedure. Radiographs taken 5 minutes after the procedure showed that abdominal distension was more pronounced in patients in the air insufflation group. There were no differences in Pco₂ values between the two treatment groups. Conclusions: Carbon dioxide insufflation during ERCP significantly reduces postprocedural abdominal pain. No side effects were observed. Carbon dioxide should be the standard gas used for insufflation in ERCP.

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