• Advise patients that colon cleansing has no proven benefits and many adverse effects. B
• Ask patients with otherwise unexplained nausea, vomiting, or diarrhea if they engage in colon cleansing. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
CASE 1 A 31-year-old African American woman sought treatment at her local emergency department (ED) for nausea, vomiting, and diarrhea. She reported passing more than 6 yellowish-brown, watery, nonbloody stools during the previous 2 days. She felt weak, feverish, and light-headed and showed signs of dehydration.
The patient had Crohn’s disease and had undergone a partial colectomy 5 years earlier. She told the ED physician that 2 days before visiting the ED she had gone to a “cleansing center” for a colonic cleansing, but was unable to complete the process because she developed cramps 15 minutes into the procedure. Less than an hour later, she developed diarrhea, nausea, and vomiting.
In the ED, her serum potassium was 2.9 mEq/L, blood urea nitrogen was 26 mg/dL, and creatinine was 1.9 mg/dL. She was afebrile, with a blood pressure of 135/75 mm Hg and a heart rate of 113 beats per minute. After receiving 2 liters of normal saline and 90 mEq of potassium chloride replacement, the patient felt better and was later discharged from the ED.
Three days later, the patient came to our residency clinic. She described her stools as being loose, but not watery or bloody, and passed in small amounts, about 4 times daily. She still had some abdominal cramping just before passing stool, but bowel movements relieved that. Her vital signs were within normal limits, and her physical exam was benign. The patient was instructed to follow her normal diet, as tolerated, and drink plenty of fluids to maintain good hydration. Her symptoms resolved by the following week.
CASE 2 A 49-year-old African American man came to our community hospital because of vomiting, diarrhea, and abdominal pain he had been experiencing for 4 days. He linked the symptoms to eating a large fast-food breakfast, followed by a big lunch the day before. He described having multiple episodes of nonbloody, nonbilious vomiting, nonbloody watery diarrhea, and “twisting” abdominal pain that was constant but temporarily relieved with a warm compress or positional maneuvers. He had never had a similar episode and had not taken any antibiotics recently.
Upon further questioning, the patient revealed that he had used a colon cleanser a few days earlier. A review showed that he had lost 24 pounds in 10 days. Vitals were within normal limits. Serum potassium was 2.9 mEq/L, and creatinine was 2.1 mg/dL. A computed tomography scan of the abdomen revealed moderate to moderately severe dilatation of multiple small bowel loops with multiple air fluid levels, suggesting an early or partial small bowel obstruction. We obtained a surgical consultation, but surgery was not required. He was discharged after 2 days.
The patient returned to the hospital 3 days later with similar symptoms and severe weakness associated with dizziness. At that time his serum potassium was 2.4 mEq/L and creatinine was 4.0 mg/dL. Aspartate aminotransferase was 29 U/L, alanine aminotransferase was 80 U/L, lipase was 418 U/L, and amylase was 94 U/L.
The patient was readmitted for dehydration, hypokalemia, and pancreatitis and, following a colonoscopy and biopsy that revealed chronic and acute inflammation, a gastroenterologist made a diagnosis of “herbal intoxication.” The patient was hydrated, his electrolytes were replaced, and his diet was slowly returned to normal. He was discharged after 5 days.
An old practice rediscovered
Colon cleansing has been around since ancient times, when its purported benefits were based on the belief that intestinal waste can poison the body (“autointoxication”).1 The procedure became popular in the early 1900s, but in a 1919 paper, the American Medical Association discounted the autointoxication theory and condemned the practice.1 The procedure then fell out of favor, albeit temporarily.2 Colon cleansing has staged a comeback in recent years.
Colon cleansing basics
Colon cleansing, also called colonic irrigation or colonic hydrotherapy, is performed by colonic hygienists or colon therapists, or can be self-administered. The procedure works like an enema. The patient generally lies on a table and water (with or without additional herbs or compounds) is pumped through the rectum via a tube.
Unlike enemas, for which a small amount of fluid is used, however, colon cleansing calls for a large volume of fluid—up to 60 liters—to be introduced into the rectum.3,4 Fluids and waste are expelled through another tube. The procedure may be repeated several times.