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Journal of Digestive Diseases 2015; 16; 747751

doi: 10.1111/1751-2980.12302

Original article

Evaluation of abdominal circumference and salivary amylase

activities after unsedated colonoscopy using carbon dioxide
and air insufations
Shinsuke KIRIYAMA,* Hiroshi NAITOH,* Minoru FUKUCHI,* Kazuhisa YUASA, Katsuhiko HORIUCHI,
Takaharu FUKASAWA,* Yuichi TABE,* Hayato YAMAUCHI,* Masaki SUZUKI,* Tomonori YOSHIDA,*
Yutaka SAITO & Hiroyuki KUWANO
Departments of *Surgery and Gastroenterology, Gunma Chuo Hospital, and Department of General Surgical
Science, Graduate School of Medicine, Gunma University, Maebashi, Gunma, Endoscopy Division, National
Cancer Center Hospital, Tokyo, Japan

OBJECTIVE: To assess and compare abdominal

distention and stress in unsedated colonoscopy using
carbon dioxide (CO2) and air insufations.
METHODS: Two hundred and ve patients
underwent colonoscopic examinations without sedation using either CO2 or air insufation. Abdominal
circumference and salivary amylase (sAMY) activities
before and 0 and 15 min after colonoscopy were measured by a nurse who was blinded to the grouping of
the patients.
RESULTS: In all, 102 and 103 patients were
randomly recruited in the CO2 and air insufation
groups, respectively. sAMY activities before and 0
and 15 min after colonoscopy were not signicantly
different between the two groups. Abdominal
KEY WORDS:
amylase.

circumference measured immediately and 15 min after colonoscopy was signicantly smaller in CO2 insufation group than in the air insufation group
(81.2 cm vs 84.0 cm, and 79.7 cm vs 83.6 cm, respectively; P <0.05). The increasing ratio of abdominal circumference immediately after colonoscopy was not
signicantly different between the two groups; however, the ratio at 15 min after colonoscopy using
CO2 insufation was signicantly lower than that in
the air insufation group (1.007 vs 1.028, P <0.001).
CONCLUSION: sAMY activities after unsedated colonoscopy using CO2 insufation were not improved;
however, CO2 insufation decreases abdominal circumference after colonoscopy compared with air
insufation.

abdominal circumference, abdominal distention, carbon dioxide, colonoscopy, salivary

Correspondence to: Shinsuke KIRIYAMA, Department of Surgery, Gunma

Chuo Hospital, 1-7-13 Koun-cho, Maebashi, Gunma, 3710025, Japan.
Email: drkiriyama@yahoo.co.jp
Conict of interest: None.

2015 Chinese Medical Association Shanghai Branch, Chinese

Society of Gastroenterology, Renji Hospital Afliated to Shanghai

Jiaotong University School of Medicine and Wiley Publishing Asia
Pty Ltd

INTRODUCTION
Colonoscopy is important for the screening and surveillance of colorectal cancer (CRC).1,2 However,
some patients complain of abdominal distention
and pain during and after the procedure. Recently,
carbon dioxide (CO2) insufation has been reported
to be able to reduce pain and abdominal distention
after colonoscopy.3,4 And its safety and efcacy in

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S Kiriyama et al.

colonoscopy have been assessed in published studies.59 CO2 can be rapidly absorbed and excreted
through the lungs. And CO2 insufation has been
reported to be safe and effective for lengthy endoscopic treatments for patients with colorectal lesions
under conscious sedation.10,11 However, air insufation remains the standard method in many institutions due to a lack of suitable equipments for CO2
insufation, and the high costs of regulator and
cylinder.
Gas in the gastrointestinal tract directly causes
abdominal distention, leading to an increase in
abdominal circumference. Furthermore, abdominal
distention can increase the stress for the examination.
A relationship between salivary amylase (sAMY) activities and the stress of endoscopic examinations has been
reported.12 In addition, abdominal circumference and
sAMY activities are useful to objectively evaluate abdominal distension. In this study we aimed to evaluate abdominal distention and stress related to
unsedated colonoscopy with CO2 or air insufation
using abdominal circumference and sAMY activities.

PATIENTS AND METHODS

Patients
This study prospectively enrolled outpatients who
underwent colonoscopy between February 2010 and
December 2011 at the Gunma Chuo Hospital (GCH)
in Gunma, Japan. The indications for colonoscopic
examination included CRC screening, surveillance for
polyps, positive fecal occult blood test, abdominal
symptoms and anemia. Patients with severe chronic occlusive pulmonary disease, cardiac diseases, benign prostatic hypertrophy, post-pelvic or gynecologic operation
and known CO2 retention were excluded from the
study. In addition, patients received sedation agents
during the procedures were excluded. Written informed consent was obtained from each patient
before colonoscopy. During the procedure, all patients
underwent colonoscopy with either CO2 or air insufation after randomization using sealed envelope
method in a single-blinded manner. The study protocol was approved by the Institutional Ethics Committee of GCH.

Journal of Digestive Diseases 2015; 16; 747751

Scopolamine butylbromide (10 mg) was administered
intramuscularly to avoid bowel movement prior to
the examination.
No patients received any sedation agents during or
after the procedure. The time required for insertion
of the endoscope to the cecum or for the entire
procedure was recorded. The procedures were
performed by three experienced endoscope operators
(Shinsuke KIRIYAMA, Kazuhisa YUASA and Katsuhiko
HORIUCHI) using a video endoscope with a distal tip
diameter of 11.3 mm (PCF-Q260AI; Olympus Medical Systems, Tokyo, Japan). All operators had
performed colonoscopy in over 3 000 cases before
this study.
In this study CO2 was administered using a CO2
regulator (UCR; Olympus Medical Systems) connected
to the endoscope supply tube, and a ow indicator provided visual conrmation that CO2 was being delivered.
During the procedures, CO2 was set to a constant rate of
1.0 L/min. In the air group, airow was set to low
ination.
All adenomatous and cancerous polyps were removed
only during withdrawal of the endoscope and were
evaluated histopathologically. The abdominal circumference and sAMY activity were recorded as objective
data before the examination, and 0 and 15 min after
the examination. Abdominal circumference was measured at the level of the umbilicus. Increasing abdominal circumference ratio was calculated as the
circumference immediately or at 15 min after examination with respect to the pre-examination value. The
sAMY activity was measured using enzyme analysis
equipment (Salivary Amylase Monitor; NIPRO, Osaka,
Japan). Both abdominal circumference and sAMY
activity were measured by a nurse who was blinded
to the nature of insufation.
Statistical analysis
Statistical analyses were performed using SPSS IBM,
Armonk, NY, USA). The variables were presented
as mean standard deviation (SD), and compared
using Students t-test or Chi-square test. A two-sided
and P < 0.05 was regarded as statistical signicance.
RESULTS

Colonoscopy using CO2 or air insufation

All patients ingested 2 L of polyethylene glycol
electrolyte solution on the morning of the procedure.

A total of 205 outpatients who underwent colonoscopy without sedation were included in the study. Of
these patients, 102 (68 men and 34 women) received

2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Afliated to Shanghai Jiaotong University School

of Medicine and Wiley Publishing Asia Pty Ltd

Journal of Digestive Diseases 2015; 16; 747751

CO2 insufation for colonoscopy

CO2 insufation and the remaining 103 patients (62

men and 41 women) received air insufation.
Complete insertion to the cecum was performed in all
cases. In the CO2 insufation group, the body mass
index (BMI) of the patients was 22.6 2.9 kg/m2, and
the total examination time and insertion time to the cecum were 22.7 11.9 min and 5.9 3.5 min,
respectively. Whereas in the air group, the BMI was
23.4 3.0 kg/m2, and the mean total examination time
and insertion time to the cecum were 24.2 12.6 min
and 6.6 3.8 min, respectively. There were no
signicant differences between the two groups in baseline characteristics of the patients including age, sex,
BMI and the examination time (Table 1). No
procedure-related complications were observed in
either group.
The sAMY activity before, 0 and 15 min after examination was 47 55 kU/L, 30 49 kU/L, and 49 kU/L
55 kU/L in the CO2 insufation group and 51 64
kU/L, 33 44 kU/L, and 44 58 kU/L in the air insufation, respectively (Table 2). There were no signicant
differences in the sAMY activity between the two groups
at the time of measurements.
The mean abdominal circumference before, 0 and 15
min after examination was 79.2 cm 8.1 cm, 81.2
cm 7.9 cm, and 79.7 cm 8.2 cm in the CO2 insufation group and 81.4 cm 9.2 cm, 84.0 cm 9.3
cm, and 83.6 cm 9.0 cm in the air insufation group,
respectively (Table 2). There were signicant differences in the abdominal circumference at 0 and 15
min after colonoscopy between the two groups. There
was no signicant difference in the increasing ratio of
abdominal circumference immediately after the procedure (0 min) with respect to pre-examination values
between the two groups (1.026 0.024 in the CO2 insufation group and 1.032 0.034 in the air insufation group). However, the increasing ratio at 15 min
Table 1.

749

after colonoscopy in the CO2 insufation group was

signicantly lower than that in the air insufation
group (1.007 0.027 vs 1.028 0.038, P <0.001).

DISCUSSION
Abdominal pain after colonoscopy is a common
distressing symptom which results from bowel distension by insufated gas during the colonoscopy and the
retention of gas in the colon.13,14. Recently, CO2 insufation was reported to reduce pain and abdominal
discomfort during and after colonoscopy.15 Sumanac
et al. revealed that insufation of CO2 rather than air
signicantly reduced abdominal pain and bowel distention after colonoscopy based on the evaluation of
pain scores and residual colonic gas on abdominal radiograph.16 Church et al. revealed signicantly less abdominal pain 10 min after colonoscopy with CO2
insufation using a 10-point analog scale.17 They recommended CO2 as the insufating gas for
colonoscopy.
In many Western studies evaluating abdominal pain
and distention after colonoscopy, patients were
sedated with propofol or midazolam.18 In Japan routine colonoscopic examinations are usually performed
without sedation, especially for outpatients. In this
study we evaluated abdominal distention and stress
related to colonoscopy for patients without sedation
using abdominal circumference and sAMY activity. We
hypothesized that abdominal circumference increased
due to the quantity of gas immediately after colonoscopy and sAMY activity increased due to the stress of
the examination to compare CO2 insufation and air
insufation in patients without sedation.Therefore, abdominal distention and stress were estimated objectively without the inuence of sedation. Unlike our

Patients characteristics

Age, years [mean (range)]

Sex, n (male/female)
BMI, kg/m2 (mean SD)
Examination type, n
Observation (including biopsy)
EMR/polypectomy
Total examination time, min (mean SD)
Insertion time to cecum, min (mean SD)
Complications, n

CO2 insufation group

(n = 102)

Air insufation group

(n = 103)

60 (2788)
68/34
22.6 2.9

61 (2883)
62/41
23.4 3.0

65
37
22.7 11.9
5.9 3.5
0

63
40
24.2 12.6
6.6 3.8
0

P value
NS
NS
NS
NS

NS
NS
NS

BMI, body mass index; CO2, carbon dioxide; EMR, endoscopic mucosal resection; NS, not signicant; SD, standard deviation.

2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Afliated to Shanghai Jiaotong University School
of Medicine and Wiley Publishing Asia Pty Ltd

750
Table 2.

Journal of Digestive Diseases 2015; 16; 747751

S Kiriyama et al.

Abdominal circumference and salivary amylase (sAMY) activity before and after colonoscopy

sAMY, kU/L (mean SD)

Pre-examination
Post-examination (0 min)
15 min after colonoscopy
Abdominal circumference
Actual measured value (cm)
Pre-examination
Post-examination (0 min)
15 min after colonoscopy
Increasing ratio of abdominal circumference
Post-examination (0 min)
15 min after colonoscopy

CO2 group

Air group

P value

47 55
30 49
49 55

51 64
33 44
44 58

NS
NS
NS

79.2 8.1
81.2 7.9
79.7 8.2

81.4 9.2
84.0 9.3
83.6 9.0

NS
<0.05
<0.005

1.026 0.024
1.007 0.027

1.032 0.034
1.028 0.038

NS
<0.001

CO2, carbon dioxide; SD, standard deviation.

hypothesis, CO2 did not increase the sAMY activity but

improved abdominal distention immediately.
The increase in abdominal circumference at 15 min
after colonoscopy was smaller in the CO2 insufation
group than that in the air insufation group. The
rapid absorption of CO2 from the colon may underlie this observation. We also demonstrated that
CO2 insufation signicantly reduces abdominal
circumference compared with air insufation.

Abdominal distention during colonoscopy is another important problem. It is necessary to evaluate

also abdominal distention during procedure in the
future.
In conclusion, this study demonstrated that CO2 insufation reduced the gaseous abdominal distention;
however, it did not reduce sAMY activity shown as
stress of patients after colonoscopy without sedation.
ACKNOWLEDGEMENT

Patients were not sedated in this study; therefore,

the stress including abdominal distress was evaluated immediately after colonoscopy without the
measurements of inuence of a sedative. In addition to abdominal circumference, the measurements
of sAMY activity performed by a nurse who was
blinded to the insufations were objective numerical measurements. The results of this study are opposite to our hypothesis as sAMY activity increased
immediately after colonoscopy because of the stress
related to the examination; however, the sAMY activity decreased after examination. The salivation
decline as a side effect of the scopolamine
butylbromide is considered as another reason for
the decline in sAMY activity just after colonoscopy
in both groups.
In this study sAMY activity did not improve using CO2
insufation compared with air insufation. Stresses
during colonoscopy are related to a variety of factors
such as preparation and anxiety for examination
rather than insufation alone. More improvements
are still required to reduce the stress during
colonoscopy.

This study was nancially supported in part by a Grantin-Aid for Cancer Research (18S-2) from the Japanese
Ministry of Health, Labor and Welfare.

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2015 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Afliated to Shanghai Jiaotong University School
of Medicine and Wiley Publishing Asia Pty Ltd