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

https://doi.org/10.1016/j.gie.2008.05.067Get rights and content

Background

Insufflation of the lumen is required for visualization during GI endoscopy. Carbon dioxide (CO2) has been proposed as an alternative to room air for insufflation.

Objectives

To assess the safety and efficacy of CO2 insufflation for endoscopy.

Design

Systematic review that focuses on evidence from randomized controlled trials (RCT).

Methods

Two investigators independently searched MEDLINE from 1950 to February 13, 2008, to identify all articles that reported the use of CO2 in a GI endoscopy application. Bibliographies of relevant articles were also hand searched to identify other pertinent reports. Data from RCTs, as well as from nonrandomized studies, were extracted.

Results

Nine RCTs were identified that compared CO2 and air insufflation for GI endoscopy. Fifteen other nonrandomized studies or reports were also reviewed. In the 8 RCTs in which postprocedural pain was assessed, pain was lower in the CO2 insufflation group compared with the air group. Two RCTs found decreased flatus in the CO2 group compared with the air group, and 3 RCTs showed there was decreased bowel distention on abdominal radiography in the CO2 group compared with the air group. Also, in all 9 RCTs and 6 additional studies in which safety was assessed, there was no CO2 retention and no adverse pulmonary events related to CO2 insufflation.

Limitations

Because of study heterogeneity, meta-analytic techniques could not be used.

Conclusions

Consistent RCT evidence indicates that CO2 insufflation is associated with decreased postprocedural pain, flatus, and bowel distention. CO2 insufflation also appears to be safe in patients without severe underlying pulmonary disease.

Section snippets

Methods

Two investigators (E.S.D., J.S.H.) independently performed a search of the medical literature from 1950 through February 13, 2008, as indexed by MEDLINE by using the PubMed search engine (www.pubmed.gov). To capture all potentially relevant articles with the highest degree of sensitivity, the search terms were intentionally broad. We used “carbon dioxide and (endoscopy or colonoscopy).” Attempts to narrow the search strategy, for example, by excluding terms such as “laparoscopy” or

Search strategy

The initial search strategy yielded 2221 publications (Fig. 1). The vast majority of these (2197) were excluded because they were off topic, which was because of the intentionally broad initial search criteria. The remaining 24 publications were reviewed in full. Of these, 9 were randomized controlled clinical trials from which data were extracted (6 studied colonoscopy,3, 7, 9, 10, 11, 12 and 1 each studied flexible sigmoidoscopy,8 ERCP,4 and DBE14). Data from these trials are presented in

Discussion

GI endoscopic procedures are widely performed for diagnostic and therapeutic purposes, and visualization of the mucosa relies on insufflating gas to distend the lumen of the GI tract. In the United States, “room air” is typically used for insufflation.2, 3, 4 However, because ambient air is not well absorbed and must either be suctioned before the end of the procedure or passed from the GI tract as flatus, there is the potential for residual air to cause bowel distention and abdominal pain. CO2

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    DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. This work was funded in part by the National Institutes of Health training grant T32 DK007634.

    See CME section; p 914.

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