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*Associate Professor, National College
of Naturopathic Medicine, +Director of Research, National College of Naturopathic
Medicine, Portland, Oregon 97216
Received 3 August
1989, revised 15 January 1990, accepted for publication 1 February 1990
Seventeen volunteers receiving a
series of 3 colonic irrigation treatments during a one week period were evaluated
for serum electrolyte changes following treatment. Serum electrolytes measured prior
to the first treatment and immediately before and after the third treatment demonstrated
significant (p>.05) decreases in serum Na+ and Cl-. These values did not fall
below clinically significant levels, nor did any of the patients experience symptoms
associated with hyponatremia or hypochloremia. Calcium, potassium, and phosphorus
levels remained unchanged.
Introduction
Colon irrigation is a traditional
naturopathic technique frequently used in the preparation for colorectal endoscopy,
radiology and surgery, and for the treatment of constipation and various disorders
associated with endotoxemia of fecal origin1. Several published reports have described
significant, sometimes fatal, water and electrolyte imbalances following enemas
or colonic irrigation 2-1l (Table 4). To address this issue, we compared serum electrolyte
concentrations before and after a series of three colonic treatments given in a
one week period using filtered tapwater. The patients seen in this study were ambulatory
and free of serious pathology.
Methods
Seventeen volunteers (11 females,
6 males) ages ranging from 22-54 years, were recruited by advertisement from the
student externs and patient population at the Portland Naturopathic Clinic. Pre-experiment
history and physical examination were performed to exclude any person with cardiovascular
disease, including hypertension, congestive heart failure and angina, renal or metabolic
disease, bowel obstruction or inflammatory disease.
Serum electrolytes were measured
by a single reference laboratory, using an automated multi-channel instrument, prior
to the first treatment and immediately before and after the third treatment.
Treatments were administered by
trained personnel using a Dotolo Model 1085-SV Colon Hydrotherapy Instrument equipped
with an inline cotton matrix filter capable of removing particles greater than 5
microns in diameter. Water temperature was monitored in line and kept to a range
of between 95 to 100 degrees Fahrenheit. Infusion pressure was limited to less than
1.25 pounds per square inch, and the number of fill-empty cycles was recorded for
each treatment. The water was retained and released under operator control according
to subject comfort. Each treatment consisted of repeated fill-empty cycles for approximately
45-60 minutes. Abdominal massage was applied during the evacuation phase of each
cycle according to subject comfort. Subjects were placed in supine or left lateral
decubitus position during the treatment. After treatment, the subjects were instructed
to evacuate remaining stool and water in a sitting position prior to post-treatment
laboratory measurement.
Serum electrolytes were evaluated
by one way analysis of variance for comparisons between the three groups. Two-tailed
T-tests were performed to analyse differences between the two groups. All hypothesis
tests were done with p=.05 as a significance level.
Results
Seventeen individuals, 11 female
and 6 male, were enrolled in the study. All completed the series of three colonic
hydrotherapy treatments without complications or complaints. The serum electrolyte
values taken at baseline, immediately prior to 3rd treatment, and immediately following
the 3rd treatment are presented in Table 1.
Several subjects experienced altered
serum electrolytes. These included elevated potassium levels in one subject recorded
after the final treatment, and lowered serum sodium in a second subject. Three subjects
had slightly elevated serum phosphorus levels. Four had slightly elevated serum
chloride levels. None of the subjects experienced any discomfort or complications
from the treatments.
Significant variations in pre- and
post-treatment values were noted in serum sodium and chloride levels (Table 2).
The samples taken immediately after the third treatment demonstrated significantly
lower sodium and chloride levels than both the baseline and pre-3rd treatment samples
(Table 3).
Variations in pre and post treatment
calcium, potassium and phosphorus levels were not significant (Tables 2 and 3).
Discussion
In the present study, 17 healthy
volunteers with no history of bowel pathology were subjected to moderately vigorous
colonic irrigation without any resulting symptoms in spite of the occurence of some
disturbances in several serum electrolytes. The frequency and technique of the treatments
was chosen to represent common practice among naturopathic physicians and colon
hydrotherapists.
This study provides grounds for
safe use of colon hydrotherapy in patients without high risk of water intoxication.
Table 4 summarizes the history of published reports of complications following enemas.
Jolley reported the death of a 4 year old girl with no prior history of bowel disease,
following enemas equivalent to about 15% of body weight.4 In 1958 Ziskind and Gellis
reviewed the incidence and mechanisms of water intoxication via enemas.7 In their
own experiment they were unable to demonstrate electrolyte or clinical complications
following water enemas of a volume equivalent to 3.5% body weight in 11 children
with "normal" colon function. On the contrary, they reported five cases of electrolyte
imbalance following rectal infusion of water equivalent to 2.5 to 3.5% body weight
in children with congenital megacolon or chronic atonic constipation. They concluded
that "in all cases of fatal water intoxication following enemas... hypotonic solutions
were administered by several routes many times in succession before producing symptoms."
They also reported one case of severe electrolyte imbalance in a febrile child given
seven enemas in four hours totaling over 60% of body weight. This child had no prior
history of bowel dysfunction, but was experiencing febrile seizures before and during
the series of enemas. In 1976, Jacob et al. described death due to hyponatremia
and bowel perforation in a 14 month-old girl without prior bowel abnormality following
enemas of 9% body weight.8
TABLE 1. Serum electrolytes (n = 17). 1 = pretreatment. 2= prior to 3rd treatment.
3= after 3rd treatment
It is clear from the above reports
that tapwater enemas can indeed be instruments of harm and even death. As the usual
colonic irrigation technique employs tapwater, it is desirable to establish criteria
for assessing risk. A review of the mechanisms involved in water intoxication is
of interest at this point.
When hypotonic solutions such as
tapwater are placed in the colon, a quot;water reservoirquot; is created which is
rapidly absorbed by passive diffusion into the capillary network of the colonic
mucosa along osmotic gradients. At the same time, there is an osmotically-driven
loss of plasma electrolytes into this hypotonic reservoir.12,13 As circulating plasma
concentrations of electrolytes decrease and plasma water increases, tissue cells
are also forced to equilibrate water and electrolytes, resulting in tissue edema,
including increased intracranial pressure.14 This latter phenomenon was demonstrated
on laboratory animals by Rowntree in 1926 (15) and clinically confirmed by several
accidental cases in humans (Table 2). The clinical findings in cases of acute water
intoxication are those of hyponatremia, hypokalemia, acid-base imbalance and increased
intracranial pressure. Symptoms of water intoxication include weakness, anorexia,
sweating, abdominal distension, increased urination of very dilute urine, cyanosis,
pulmonary edema, confusion, coma, convulsions and death due to cerebral and/or pulmonary
edema.2,10
The extent to which water intoxication
occurs in any case will be determined by several factors:
i. Pretreatment dilution or depletion
of serum electrolytes following dietary re-striction, parenteral fluid administration,
hemorrhage, renal disease or heart failure will decrease the body's ability to compensate
for rapid absorption of hypotonic fluids.
ii. The osmolality of fluids infused
into the colon determines the rate and direction of net electrolyte exchange between
the serum and the intracolonic fluid reservoir. Tapwater is typically hypotonic
for all key serum electrolytes.
iii. The larger the total surface
area of membrane in contact with the hypotonic reservoir within the gut lumen, the
greater the loss of serum electrolytes. This is a function of the degree of "stretch"
to the colonic mucosa caused by the hydrostatic pressure of the enema fluid. This
surface area is larger in patients with distended colons, as in atony and congenital
megacolon.
TABLE 2. Serum electrolyte levels pre and post colon hydrotherapy treatment. * =
significant at 0.05 level. #1 = pretreatment. #2 = prior to 3rd treatment. #3 =
after 3rd treatment.
TABLE 3. Sample means, difference and T-Test values. * = significant at the 0.05
level.
TABLE 4. Reported complications of hypotonic enemas. BW= body weight. * In all cases
where data were available, serum electrolytes disturbances were found.
iv. Greater duration of retention
of the hypotonic solution leads to greater elec-trolyte depletion. This factor is
depend-ent on gut motility and enema technique, and poses an increased risk in patients
with local or systemic necrologic deficits such a congenital megacolon or spinal
paralysis. The use of isotonic electrolyte solutions has been necessary to prevent
complications of frequent enemas in patients with impaired motility. Simple instructions
for the preparation of iso-tonic solutions are available.5,1
v. Serum dilution by hypotonic solutions
is proportional to the hydrostatic pressure exerted by that solution upon the colonic
mucosa. Bowel tone and enema technique are the controlling factors. The typical
hospital enema delivers pressures of 2-4 psi, depending on the height at which the
canister is held. Pressure in our study was 1.25 psi.
vi. The greater the total volume
of the hypotonic solution entering the body (by any route), the greater the likelihood
of water intoxication.
vii. The ability of the kidneys
to excrete dilute urine determines the ability to recover from acute water overload.
Important differences exist between
conventional enemas and colonic irrigation of the type used for the present study.
First, enemas are usually a measured volume, typically one-half liter for children
and one to three liters for adults. Many colonic irrigation instruments, including
the one used for our study, provide no means of volume measurement. However, reported
cases of water intoxication in patients without bowel pathology occurred in enemas
of 1500 to 7000 cc in children and several liters per day for many consecutive days
in adults. In our study, most subjects underwent 18 to 20 intake-output cycles per
treatment, and many remarked that the volume of water was very large in comparison
with previous treatments they had received. However, closed system colon irrigation
equipment, such as that used in our study, uses a considerable volume of water to
flush the tubing during the evacuation stage of each fill--empty cycle. Thus we
were unable to measure the exact volume of water entering the colon during any treatment.
Secondly, enemas are usually expelled
in a sitting position after brief retention, while colonic irrigation fluid is expelled
in a lying position, under therapist control. Colonic irrigation probably allows
for greater retention of water in the colon than does enemas.
In spite of the considerable duration
of treatment and volume of water used in our study, the subjects experienced none
of the symptoms of water intoxication. Our experience at the Portland Naturopathic
Clinic has been that even in debilitated and chronically constipated patients, serious
reactions to colonic hydrotherapy has not occurred.
The data presented here may help
support the safety of hypotonic solutions employed in colonic irrigation in normal
patients with no known risk factors for acute water intoxication, such as neurogenic
constipation, heart failure, renal failure and recent fluid electrolyte depletion
or dilution. Further study is warranted to determine the effect of colonic irrigation
on water and electrolyte balance in patients at risk of water intoxication, including
the elderly, who are more prone to cardiovascular complications of electrolyte depletion.16
These studies should include measurement of the infused water volume, duration of
water retention, and the mineral concentration of the solutions infused into the
colon with each treatment.
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