Sunday, February 24, 2013

Enemas and IBD

Enemas:  The Back Story

An enema is the introduction of liquid into the rectum from the direction opposite that of digestion – i.e. through a tube inserted into the anus.  Enemas (or Cylsters, for ye olde word for enemas) have been around for hundreds of years.  They were popular forms of “treatment” in the pre-scientific medical world, and were popular in Victorian times as everything from a cure for cholera to a disciplinary measure.  Enemas have consisted of everything from soapy water to tobacco (while a nice story, there isn’t much evidence to this being the origin of “blowing smoke up one’s ass”).(1)  Compulsive enema use for sexual gratification (klismaphilia) is even a recognized paraphilia in the DSM IV-TR. (2) 

The enema is touted as a miracle cure as part of several dubious, unproven, and sometimes dangerous regimes.  It is also used in modern medicine for science-based treatment and procedure preparation.  What does the evidence tell us about some popular enema uses, and what are their impacts on individuals with IBD.*

Coffee Enemas

Coffee enemas were popularized as part of the Gerson Therapy, developed in the 1940’s by a German-born doctor practicing in the United States as part of a treatment for headaches.  The treatment was expanded to include everything from arthritis to cancer, and is still perpetuated on many sites online.  The American 
Cancer Society summarizes the treatment very well:
Available scientific evidence does not support claims that Gerson therapy is effective in treating cancer, and the principles behind it are not widely accepted by the scientific and medical communities. It is not approved for use in the United States. Gerson therapy can be dangerous. Coffee enemas have been associated with serious infections, dehydration, constipation, colitis (inflammation of the colon), electrolyte imbalances, and even death.(3)

Coffee enemas cause inflammation of the colorectal area, and have been a cause of everything from acute colitis (something those with IBD should be keenly aware of) to rectal burns.(4,5)  There have been multiple deaths related to septicemia and electrolyte imbalances from this practice also.  There are no clinically sound trials showing any benefits to this treatment for any condition, and the exacerbation of IBD symptoms is likely given the known side effects.  As such, there is never any reason for those with IBD to engage in coffee enemas based on the current research.

Colonic Cleansing

Colonic hydrotherapy uses enemas and enema-like treatment to combat “autointoxication”, a poisoning of the body by intestinal waste.  It generally involved irrigating the bowels in a clinic using large amounts of water pumped in through the rectum (there are other forms that are laxative based, but this covers the enema-based ones).  The water may or may not contain other compounds, depending on the setting.  There are two problems with this, there is no evidence (or viable mechanism of action) for autointoxication and the enemas themselves can have side effects.  Colon irrigation has limited medical uses that will be covered in a future article, but the application is short term and to address post-surgical issues (there is some evidence of efficacy for neurogenic bowel dysfunction treatment as well).

A 2009 systemic review of the available studies on colonic cleansing concluded:
there are no methodologically rigorous controlled trials of colonic cleansing to support the practice for general health promotion. Conversely, there are multiple case reports and case series that describe the adverse effects of colonic cleansing. The practice of colonic cleansing to improve or promote general health is not supported in the published literature and cannot be recommended at this time.(7)

The adverse events associated with this form of enema include hypokalemia (potassium imbalance), rectal perforation, and amebiasis (an intestinal infection that killed at least 6 people in once colon cleansing clinic case).(8,9,10)  The risk of infection and electrolyte imbalance and lack of efficacy would contraindicate use by those with IBD, who may be on immunosuppresants and already have electrolyte imbalance risks due to chronic diarrhea and malabsorption. 

Sodium Phosphate Enemas

The most common use of enemas is the over-the-counter purchase of products for self-administration and treatment of motility issues.  Simply put, people use the enema products they can purchase at the grocery store to self-treat constipation and similar concerns (or to address the not proven “autointoxication” noted above).  They can also be used medically in procedure prep and post-procedure treatment.
While commonly believed to be an effective treatment for constipation, the clinical evidence is lacking.  There have been no comprehensive studies showing that these enemas are effective for the treatment of constipation.(11)

A comprehensive review of the risks associated with these enemas found that electrolyte imbalance and hypernatraemia were the two most common side effects.  12 deaths associated with the use of these were found, but the individuals identified were polarized as very old or very young.  There is a risk of perforation of the bowel as well, but the cases identified were due to product misuse and not the treatment itself.  While not risk free, the number of adverse events associated with these products is minimal given their prevalence and widespread usage.  Individuals suffering from reduced bowel motility (e.g. Hirschsprung's) should avoid the enemas because of increased risk of potassium imbalance. (12)

Bottom Line

·         There is no clinical evidence supporting the efficacy of sodium phosphate enemas, coffee enemas, or colon cleansing for the treatment of IBD.
·         The risks vary from minimal (sodium phosphate enemas) to high (coffee enemas) for adverse side effects.
·         Those with IBD should avoid self-directed enema treatment.  Doctor prescribed treatments of coffee enemas are not supported by the evidence, and colonic cleansing (through irrigation or sodium phosphate enemas) should be restricted to pre and post-op cleansing routines.
*The use of enemas for preparation and as a medical delivery mechanism will be covered in a separate article
1.       Multiple.  Transactions of the Medical and Physical Society of Calcutta.Volume the Seventh.  1835.
2.       Denko, Joanne D. "Klismaphilia: Enema as a sexual preference." American journal of psychotherapy.  1973.
4.       Lee, Chang Jung, et al. "Coffee enema induced acute colitis." Korean Jorunal of Gastroenterology 2008.
5.       Sashiyama, Hiroshi, et al. "Rectal burn caused by hot-water coffee enema."Gastrointestinal endoscopy.  2008.
6.       Eisele, John W., and Donald T. Reay. "Deaths related to coffee enemas."JAMA: The Journal of the American Medical Association 1980.
7.       Acosta, Ruben D., and Brooks D. Cash. "Clinical effects of colonic cleansing for general health promotion: a systematic review." The American journal of gastroenterology, 2009.
8.       Dunning, Marcelle F., and Fred Plum. "Potassium depletion by enemas." The American journal of medicine.  1956.
9.       Biering-Sørensen, F., et al. "Rectum perforation during transanal irrigation: a case story." Spinal cord 2008.
10.   Istre, Gregory R., et al. "An outbreak of amebiasis spread by colonic irrigation at a chiropractic clinic." New England Journal of Medicine. 1992.
11.   Davies, Caroline. "The use of phosphate enemas in the treatment of constipation." Nursing times.  2004.
12.   Mendoza, J., et al. "Systematic review: the adverse effects of sodium phosphate enema." Alimentary pharmacology & therapeutics.  2007.

1 comment:

  1. Coffee enema is a good technique to purify the large intestine and rectum. Nice article, Martin.

    Finn Felton
    Kopi Luwak