Colonic Irrigation Risks

Colon Hydrotherapy – What are the Risks? A Complete Review of Medical Literature 1978-2018

I decided to create this page to offer what I believe is a balanced view on colonic irrigation risks – and dangers reported around colon hydrotherapy (or commonly known as colonic irrigation).
There is a lot of confusing -or I should say incomplete information- that is misguiding patients and consumers. Hopefully this page will resolve some of that.

First of all, we should agree on basic terminology. A lot of articles and studies use the terms colon cleansing, bowel cleansing, very generally by lumping together a series of activities:
– The practice of using oral supplements (herbs or medications) for cleansing or clearing the bowels
– The practice of using enemas: this should be further split into two categories, whether enemas are self-administered or administered in a hospital or nursing home setting
– The practice of colonic irrigation or colon hydrotherapy at a colon hydrotherapy clinic: this involves a therapist that should be certified by a recognised association
– The practice of using additives in addition to water when performing enemas or as implants after colonic irrigation: phosphate enemas, but also the use of herbs and other additives.

The categories listed are all different practices, and I believe magazine articles and even research publications fail, in their summary (which is the only part accessible to the public without membership) to be very specific about which exact category they refer to. When someone is considering colon hydrotherapy and doing his/her own research, make sure you keep the above in mind.

However, it is also true that, while these risks have to be taken into account, a properly trained professional should never have any of the issues presented. Having said so, I agree that risks have to be presented clearly. I just personally feel that some magazine articles are quick to point out risks that in the overwhelming majority of cases, have been reported to be very sporadic cases.

BACKGROUND CONTEXT

I think some background context is needed in order to offer this.
We are very fortunate to have had the first colon hydrotherapists create some associations back some 30 years ago in the US and UK and many other parts of the world. ARCH was founded in 1987, and I-ACT was founded in 1989.

This has given colon hydrotherapists as a profession 30 years of practice during which many beneficial results have been observed in the day to day work with patients. Therapists all over the world have obviously shared benefits obtained from clients in a quite enthusiastic manner even when there is no medical evidence to substantiate those claims. Now anecdotal evidence does matter, but we cannot make medical claims unless benefits have been verified under a controlled environment. But I reserve a discussion about benefits for another time.
The problem I highlight above has been written about by Prof Stephen Holt MD PhD, author of the book “The Definitive Guide to Colon Hydrotherapy”. Because of this often over enthusiastic approach in claiming that colonics are good for everything under the sun, it is understandable that sceptics -or just someone with less enthusiasm about the topic- would take the other side and point out all the risks that are instead associated with the procedure. It is correct to have a balanced view, and I believe both sides have the best intentions in mind: one to protect the consumers and keep them away from charlatans, and the other wanting to help as many people as possible.

It is true, as a lot of magazine articles point out, that colon hydrotherapy carries risks and has not to be taken lightly. Someone considering colonic irrigation should definitely choose very carefully where they decide to go to have the procedure done.

Let’s take a look at the Four Main Categories of colonic irrigation risks associated with the procedure and analyse the evidence from the medical articles:
– Risks about the person: certain individuals should not have colon hydrotherapy – many studies document severe issues following colon hydrotherapy where the person simply should not have received the procedure due to contra-indications
– Risks about the procedure
– Risks about sanitary conditions of the establishment: contaminations and infections
– Risks associated with substances (herbs or other products) inserted into the colon

In some cases, a combination of these is true, for example someone who should not have the procedure due to a pre-existing condition who also had procedure done wrongly or used/abused unproven substances/products.

PRE-EXISTING CONDITIONS – CONTRAINDICATIONS

The main category of risks undertaking colon hydrotherapy or some form of self-administered enemas or implants are pre-existing conditions like diverticulitis, chron’s disease, cancer, hypertension, pre-existing electrolyte imbalances, and more.

These are red flags and are part of the contraindication list in all (as far as I know) Colon Hydrotherapy Associations curriculums around the world. In most cases the patient presenting will know that they are suffering from one of these (for example, an individual will be aware of diverticulitis as they do cause pain and discomfort) however it is always important to check the patient for suitability – this is why I insist on carrying out a thorough consultation before anyone has the treatment. Even if they had colon hydrotherapy elsewhere. Our consultation is not merely paper filling. We ask the patient to fill in the medical questionnaire in advance, so the consultation is a proper consultation where we go through the medical history and check for potential issues that may have gone unnoticed. This is especially through for medications that weaken the intestinal wall and could potentially make colon hydrotherapy harmful. I am a trained nurse, so I understand the importance of this – I feel this is an area that could be improved at Curriculum level and surprisingly one that is not mentioned much by the magazine articles but perhaps should – such articles preferring to focus on the sensationalised issues of the one in a million perforation cases mentioned above.

The following published articles report incidents with colon hydrotherapy where, looking at the details, it was administered to someone who should not have had the procedure done.

+ The Dangers of Colon Cleansing (Journal of Family Practice, 2011, Mishori et al)

https://www.mdedge.com/sites/default/files/Document/September-2017/6008JFP_Article1.pdf

The article reports a case of a 31-year-old lady with Chron’s disease who had complications following colon cleansing at a clinic in USA. The person had Chron’s disease with a partial colectomy (removal of part of the colon) from 5 years before. This should have raised multiple red flags – This person should not have been given colon hydrotherapy as Chron’s disease is a contraindication. Also, clearly due to a partial colectomy her colon was not intact and had been partially removed so further consideration should have been given to this case.

Unfortunately, I have come across a few more of these in reviewing all the papers I mention below where patients with cancer and other issues were given the treatment. This should not happen.

More importantly, and perhaps more dangerous, is people undertaking self-administered procedures without establishing first whether they are suitable or not. It is very important to make sure one is safe to go ahead, and it should not be taken lightly.

RISKS OF PERFORATION

The risk of bowel perforations is the one always mentioned in any journal. There have been cases of hospitalisation due to bowel perforation.

Let’s take a look at these in details, I examined all the articles that seems to reference perforations, and this is what I found.

+ Enema-induced perforation of the rectum in chronically constipated patients. (1999, Haim Paran, Gavriel Butnar, David Neufeld, Amalia Magen, Uri Freund, “Diseases of the Colon and the Rectum)

https://www.ncbi.nlm.nih.gov/pubmed/10613482

https://link.springer.com/article/10.1007%2FBF02236216

This is a report of findings conducted between January 1995 and December 1997 on elderly patients suffering from chronic constipation. In this report, 13 patients were reported to hospital with rectal or sigmoid perforation, following enema in 10 cases performed in nursing home and 3 cases at the patients home. For the three patients living at home, the enema was self-administered. Of the other 10 cases, only 2 were referred by the institution and we have no further data to ascertain the procedure used for the administration of the enema and whether any force was used. It has to be highlighted that all cases referred to elderly patients. Extra care should always be used when dealing with elderlies and I definitely consult the GP and/or other doctors when this is the case. In one passage it also highlights that “other abdominal pathology was found”, and mentions “repeated use of retrograde irrigation enema”. It should also be pointed out that this study refers to enemas and not colon hydrotherapy / colonic irrigation performed using a specific equipment. Nursing homes should be under medical supervision especially when dealing with elderlies, and we can only assume that for these elders the enema was a regular occurrence. It would be more useful to understand circumstances upon which those enemas were performed, how they were performed, how impacted the colon was, etc.

+ Unusual Rectal Perforation – An Individualised Approach to Management (Singapore Medical Journal, 1994 (Eu, Seow-Choen, Goh)

http://www.smj.org.sg/article/unusual-rectal-perforation-individualised-approach-management

This is more of a collection of unfortunate incidents: one case of a 24-year old construction worker who fell and landed on a metal rod and penetrated the anal canal. Another case of a 17-year-old who impaled himself while riding his bike when the seat fell off. There is however a case of a 70-year old woman who was given a barium enema that showed a sigmoid carcinoma. Following this a thorough septic work-up was done but she had complications. This is unusual but a recognised complication of the procedure. At this point, it is important to highlight that a barium enema is completely different from colon hydrotherapy, none the less the risks of barium inflammatory reaction. In most cases, this is due to weakness of intestinal wall or poor technical execution. Moreover, during barium enema air may be pumped into the colon. Nothing it pumped in the colon during a colon hydrotherapy procedure.

+ Traumatic rectal perforation presenting as necrotising fasciitis of the lower limb (Singapore Medical Journal, 2009 (Fu, Quah, Eu)

https://pdfs.semanticscholar.org/fada/b3e134d0c51ad46162066a7fcd5c5939c184.pdf

This case of rectal perforation again is a case of a 73-year old Chinese man, cancer patient. The paper, I quote, states that “Further history-taking revealed that in the week prior to presentation, he had been using tap water directly from a rubber hose inserted per rectum, as a form of irrigation enema to relieve his constipation”. Does this sound like common sense to anyone? This should not have been done at home, using a connection direct to tap water (with risk of high pressure) and by a 73-year old cancer patient.
+ Rectal perforation from colonic irrigation administered by alternative practitioners (Medical Journal of Australia, 2004, Handley, Rieger, Rodda)
https://www.mja.com.au/journal/2004/181/10/rectal-perforation-colonic-irrigation-administered-alternative-practitioners
I was not able to obtain the full paper at the time of writing of this piece. However, the abstract shows the following:

“The fluid may be driven by gravitational or mechanical force” –Recognised risks from colonic irrigation are electrolyte imbalance, bowel perforation and communicable diseases such as amoebiasis

We will go into details about these one by one. First of all, about the equipment. No colon hydrotherapy equipment does or should use mechanical force. This implies we use an external force to inject water into the bowels. All colon hydrotherapy equipment should (and is to my knowledge) using gravitational force. Simply put, the water reservoir used for the treatment is positioned above the bed where the patient lies during the treatment, and the water reaches the patient by way of gravity: this means, the person can never take more water that the body allows, and when he/she has taken enough, will feel a sense of fullness and release. Only at this point, more water than the bowels can possibly take will be gently fed again by way of gravity.

In conclusion, all these cases report someone who either self-administered, or was given a barium enema in a hospital settings, or had some pre-existing conditions that a qualified colon therapist should have checked and therefore not administered the treatment. Statistically, this does not stack up against the thousands of treatments (we alone at Aqualibria have performed over 19,000 in the last 13 years) performed all over the world by properly qualified practitioners who follow all protocol and do not administer the treatment to someone who is not suitable.

We are going to examine the other risks mentioned in the abstract above in the following paragraphs.

RISK OF INFECTION / CONTAMINATION / COMMUNICABLE DISEASES

Another risk that is often mentioned is the risk of infection and contamination. This risk is common to any treatment that involves bodily fluids which is risk of infection. This could be said of any treatment that involves needles, injections, shared surfaces. A properly sanitised clinic should never have these kind of issues (we have a dedicated hygiene assistant whose only job is to keep our clinic clinically clean), and it has been years now since all major colon hydrotherapy associations mandated the use of single-use disposable nozzles and other implements.

The following papers have been published and quoted about this subject.

+ Escherichia coli Septic Shock Following Colonic Hydrotherapy (American Journal of Medicine – Dore, Gleeson, 2015)

https://www.amjmed.com/article/S0002-9343(15)00516-1/fulltext

This case involves a 78-year-old man with a history of hyper- tension, type II diabetes mellitus, and diverticulitis 8 months before admission. The patient had undergone colonic cleansing treatments at a spa, which involved per rectum instillation of large volumes of herb-infused water into the patient’s colon. He presented with E. coli which was postulated happened because of intraluminal pressure.
Again, this person presented multiple contra-indications: This person should not have been given colon hydrotherapy because of diverticulitis, possibly hyper-tension if it was uncontrolled. And definitely not been given herb-infused water (more about this further down).

The paper above quotes another article where the contamination was due to poor sanitary conditions in the clinic:

+ An outbreak of amebiasis spread by colonic irrigation at a chiropractic clinic. (New England Journal of Medicine, 1982, Various Authors)

https://www.ncbi.nlm.nih.gov/pubmed/6283354

This case refers to 1978-1980 outbreak of amoebiasis and E-coli in a clinic in Colorado: following this, 36 cases of amebiasis occurred in persons who had had colonic-irrigation therapy at a chiropractic clinic in western Colorado. Tests conducted after concluded the equipment were not properly sanitised.
After this in the early 1980s the FDA mandated use of single-use disposable equipment that we have been using since and adopted pretty much world-wise these days and we definitely abide to this by only using single use disposables.
Since then, as documented in the 2015 article above, the only other outbreak was in an infection attributable to colonic hydrotherapy is a case of rectal perforation with polymicrobial infection in a patient who had received recent chemotherapy. One case in 35 years luckily.
Risk of contamination and infections do exist but if a clinic follows the proper sanitisation procedures, and use single use disposables, this should not happen. The same could be said about any health clinic / hospital dealing with injectables and needles. I advise the public i.e. the consumer to do your own research, check reviews and do your own research to satisfy yourself with the quality of the establishment you plan to visit.

RISK OF ELECTROLITE IMBALANCE

Other reported risks have been associated with electrolyte imbalances.

There are a couple of studies that have been done on this.

+ Effects of Colon Irrigation on Serum Electrolytes (National College of Naturopathic Medicine, Portland, Oregon,1990, Collins, Pittman)

http://www.gpact.org/electrolytes.php

This study with 17 people (11 female, 6 men) aged 22-54, had three colonic treatments in a week period, and were measured for serum electrolytes immediately after the treatments.
There was a measured drop in electrolytes but not under clinically significant levels nor any of the subjects presented any symptom.

+ The Influence of Colonic Irrigation on Human Intestinal Microbiota (Yoko Clinic, 2012, Yoko Uchiyama-Tanaka)

https://www.semanticscholar.org/paper/The-Influence-of-Colonic-Irrigation-on-Human-Uchiyama-Tanaka/b13f1ca7d24754e1a3353ff372dde3c4dc349d61

In this similar study, 10 subjects with no history of malignant or inflammatory disease had 3 colonics over the period of 2 weeks. The results are as follow: “In conclusion, colonic irrigation has no influence on serum electrolytes and may induce improvements in symptoms without any effects on the intestinal microbiota. “
There are however, risks if the individual is not healthy, has some pre-existing conditions, or some herbs or additives are used during the procedure.
We will examine this in the last section of this article.

USE OF ADDITIVES

The last category of risks that I want to mention is the use of herbs and additives. This is where some articles are mixing things up and making things confusing for the average Joe to understand, because they mix colon hydrotherapy with colon cleansing products used at home, being orally or administered via an enema. Franky, I don’t understand why the two things are being mixed in such manner. I appreciate the need to cover colon cleansing in general but it is very confusing and unfair to put apple and pears in the same basket and group together colon hydrotherapy which is a treatment that is (or should, if done by a professional) done within controlled environment and strictly defined safety guidelines, and some colon cleansing products which someone can buy off the shelf and then ingest or insert directly in the column by use of an enema.

Such articles like Mishori articles, websites like WebMD and Mayo Clinic, are very clear to point out that herbs and supplements should not be used lightly, and I agree – such use definitely falls under the umbrella of self-diagnosis and it is at best an educated guess and at worst a gamble.

I agree completely with the risks associated with potassium depletion, minerals depletion and disruption of the gut flora when using such products (which could be said by the way for the use of laxatives too), and therefore we decided as a practice not to administer any additives or implants during our colon hydrotherapy treatments. I want to see further evidence before we introduce these in our daily practice.

These articles reference the precautions to take when considering herbs and additives, whether in enema form, as an implant with or without a colonic, or ingested orally.

The following article from Mayo Clinic cautions against using herbs and additives without prior checking its suitability:
https://www.mayoclinic.org/healthy-lifestyle/consumer-health/expert-answers/colon-cleansing/faq-20058435

The Mishori article in the Journal of Family Practice – already referenced above – quotes a 49-year-old African-American who had used 3 days earlier a non-specified colon cleanser and presented to hospital with severe symptoms.

Another case study mentions a case of hyponatremia (lack of sodium).

+ Colonic irrigation-induced hyponatremia (Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia, 2004, Norlela, Izham, Khalid)

http://www.mjpath.org.my/past_issue/MJP2004.2/06-colonic.pdf

In this case, a 42-year old chinese woman “was diagnosed to have diabetes mellitus one year before but defaulted treatment; instead she was using self-prescribed herbs to control her diabetes. She visited a clinic several times, and… the procedure required her to instil (using a plastic tube) into her rectum 400-500 ml of tap or distilled water to which was added a tablespoon of apple cider vinegar or coffee … Individuals undertaking colonic irrigations were advised to take several kinds of oral supplements which include potassium salts prior to the procedure.”

I am not sure why this person would be advised to follow such a procedure because it is not part of our training. We do not require taking any supplements before undertaking colonic irrigation let alone potassium salts. And we not add apple cider vinegar or coffee to our colonics….

CONCLUSIONS

In conclusion, a properly qualified Colon Hydrotherapist – even better if they have some form of medical training or they work with referrals from doctors – should never put any patient at risk of any of the above-mentioned risks by checking things thoroughly and making sure that the patient is completely safe before administering colon hydrotherapy. Under proper safety boundaries, in a clinic that observes proper hygienic procedures, colonic irrigation risks should be minimal and none of the above should ever occur.

This is clearly indicated in the following PubMed published study:

+ Colonic irrigations: a review of the historical controversy and the potential for adverse effects” (Journal of Alternative and Complementary Medicine, 2006, Various Authors)

https://www.ncbi.nlm.nih.gov/pubmed/16722789

The article concludes that: “Although there is little specific literature on colonic irrigations, a review of the literature on related procedures such as enemas and sigmoidoscopies suggest that the risk of serious adverse effects is very low when the irrigations are performed by trained personnel using appropriate equipment.”

The key is the last part of the sentence, trained personnel and appropriate equipment. Since 2005, we delivered safely over 19,000 treatments and we never had anyone get to hospital or have any major complaints. I did turn away many clients who in my opinion were not suitable for the treatment and I do prefer to go above and beyond the safety guidelines.

Written October 2018 by: Velile Ndebele, Clinical Director RGN