Perianal Crohn's Disease
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Colon cleansing for Crohn’s disease
One approach that people have adopted to treat Crohn’s disease is colon cleansing. This article examines the role of colon cleansing in Crohn’s disease, its relative effectiveness, and certain precautions that should be considered before engaging in this practice.
The act of colon cleansing can actually encompass various things. For example, doctors prescribe a form of colon cleansing for patients that are going to have bowel surgery or a colonoscopy. This method usually requires the patient to consume a large volume of a salty solution which dissolves fecal material in the large intestine and promotes defecation. When the proper oral solution is used for colon cleansing (infrequently), it is a safe and effective method of colon cleansing.
The main alternative or complementary approach to colon cleansing is what is known as a high colonic. The overall concept is the same for both the mainstream medical and alternative approaches to colon cleansing in that fecal material is dissolved and passed from the body. However, a high colonic introduces the large volume of fluid through a tube inserted into the anus. The dissolved fecal material is removed by one or more things including gravity, gentle suction, or the body’s natural defection action.
Unfortunately fairly little has been published in the medical literature about the effect of high colonic colon cleansing on Crohn’s disease. Because of this, much of the information that is freely available is based on marketing information, anecdotal evidence, and may or may not be accurate or supported. Most physicians have hesitated to weigh in on the practice. In fact, a search of the American Gastroenterological Association and the American College of Gastroenterology websites for “high colonic” or “colon cleansing” fails to produce any results. “Colonic irrigation,” which is a more medically accepted term for the process, returned one germane result, though it was concerned with fecal incontinence rather than Crohn’s disease or IBD. PubMed, the database which houses millions of scientific citations produced very few, relevant search results and none that published results of colon cleansing or colonic irrigation in Crohn’s disease.
As with most health conditions, when there is a general lack of scientific information on the subject there is a wellspring of conjecture and possible misinformation. In this article I examine some of the major claims of the proponents of colon cleansing for Crohn’s disease and whether they make sense with what is known about the disease and the process.
The original underpinnings for colon cleansing were based on the notion of autointoxication. Autointoxication is the concept that fecal waste putrefies, is transformed into harmful proteins or other substances which enter the bloodstream, and subsequently cause disease. The theory of autointoxication was conceived in ancient Greece and persisted in medicine until the 19th century (some outside of mainstream medicine still accept the theory as true). Medical dedication to the concept of autointoxication was so profound that it was considered to be one of the major (if not only) sources of disease in humans. This belief led to the surgical removal of the colon in patients affected by a wide array of disease states. Today if you ask most physicians about autointoxication, those that have heard of it reject it out of hand, and those that have not heard of it (the majority), once informed, will dismiss it as implausible.
While the concept of autointoxication is currently not taught in medical schools (other than as a medical history) and claimed to be debunked, an evolution from autointoxication to modern concepts of microbial infection persist and are accepted to this day. In its normal state, the colon serves to extract water from the feces and to store it until defecation occurs. With the exception of the anal area, the colon does not absorb many other things beside water and small molecules. This organ does a good job at containing most of the bacteria that reside in the stool. Further, helpful bacteria that inhabit the wall of the colon prevent most infections from seeding there. In Crohn’s disease, the colon and small intestine become inflamed and many of these protective processes are deranged. Where the intestine is affected with Crohn’s lesions, harmful bacteria can more easily gain access to the bloodstream and normal, helpful bacteria usually cannot colonize effectively in these areas. While most practitioners use sterile or disposable equipment in colonic irrigation, non-sterile equipment can introduce pathogenic bacteria to the colon and potentially to the bloodstream. Also, when the intestine is inflamed in active Crohn’s disease, there is some evidence to suggest that colonic irrigation changes the bacterial flora of the gut i.e. the rinsing action removes helpful bacteria from the wall of the intestine. These normal, helpful bacteria are an important part of our body’s defense against bacterial invaders in the colon.
With what we know about the function and dysfunction of the colon, Crohn’s disease creates an interesting dilemma for medicine. Gastroenterologists will accept the notion that inflamed gut cannot form a protective barrier to organism’s can cause infectious agents to enter the bloodstream. While this is not the same autointoxication, it is similar in that contents of the colon can cause disease under certain circumstances. This state differs from autointoxication in that the primary disease is an autoimmune disease not a disease of toxins from the intestine (What will really blow your mind, however, is that immunologists theorize that autoimmune diseases are precipitated by the immune system incorrectly recognizing a infectious pathogen that has a similar protein structure to a human tissue). The currently held notion of bacterial translocation is similar to autointoxication only in that once the colon breaks down, toxic substances can enter the body and bloodstream to cause further disease. While autointoxication is not accepted by medicine, this latter disease process is.
A survey of those that perform colon cleansing, colonic irrigation, and colonic hydrotherapy show them to be split when it comes to performing this practice during Crohn’s disease. Those hydrotherapy practitioners that adhere to the autointoxication theory of disease would argue that colon cleansing or colon irrigation is an effective means of treating the disease state. If you remove the putrefied material from the colon, you will reduce/prevent disease according to this theory. Even with a more modern interpretation of autointoxication, the idea of removing bacteria from the colon should help prevent subsequent bloodstream infection across a diseased colon. The other camp, and generally those that adhere to formal training and certification for colonic hydrotherapy, argues that colon cleansing should not be performed during active Crohn’s disease. In fact, they list a number of states in which colon cleansing would be contraindicated. The reasoning behind this contraindication makes sense medically. First, the bowel is not only less able to withstand bacterial translocation (bacteria moving from gut to blood) but it is also more susceptible to perforation. In other words, in active IBD (like Crohn’s disease), the action of irrigating the colon could theoretically cause it to rupture at this point. At the very least, the diseased area could become more inflamed due to this mechanical process. The other risk, most prominent in pediatric patients, is the risk of electrolyte disturbances. Electrolyte disturbances could occur after any colonic irrigation, but may be of particular concern in a patient with active Crohn’s disease who is losing electrolytes through chronic diarrhea.
Another claim among some proponents of colon cleansing for Crohn’s disease is the issue of colonic blockage. One of the complications of the disease is that the inflamed or scar tissue constricts the internal diameter of the gut. Because of this, intestinal contents can slow or stop through this area, leading to intestinal obstruction. Unfortunately, intestinal obstruction is one of the more common complications of Crohn’s disease; as many as three-quarters of all patients with the disease will need bowel surgery to remove the constricted section of bowel. For those that may not yet need surgery, intestinal narrowing may lead to crampy abdominal pain and bloating. For this reason, colonic irrigation has been adopted by some as a method of loosening stool and clearing the obstruction without surgery. Sadly, clinically important blockage (causing symptoms for the patient) usually occurs in the small intestine where the diameter of the intestine is smaller. Irrigating the colon with fluid will rarely correct a small bowel obstruction, if ever.
As was mentioned, the medical establishment is curiously mum on the issue of colon cleansing and colonic irrigation. When Ernst wrote on the autointoxication in 1997 it was quite negative; almost emotionally so. However the role of colonic irrigation is still poorly studied and therefore it is difficult to make many definite recommendations. From a search of clinicaltrials.gov, listings of eight trials return from a search of colonic irrigation and only one is tangentially relevant to the current topic. This trial looked at colonic preparation techniques prior to colonoscopy and included no patients with active IBD.
Where does that leave the consumer and the patient? In a difficult position, really. We do not know enough about colon cleansing in Crohn’s disease to make any firm recommendations. It seems reasonable, however, that colonic irrigation should be avoided by anyone with active Crohn’s disease. This is the position of mainstream hydrotherapists and seems to be well-informed. Autointoxication arguments aside, the bowel is inflamed and quite unhealthy during an active flare-up of Crohn’s. The risk of creating other and more serious problems is too great. The role of colonic irrigation between disease flare-ups is open to some discussion but is likely ill-advised. One issue is that it is not always possible to know when the disease is active, especially in the early and late stages of a flare. Changes take place within the gut prior to the patient noticing symptoms and after the bulk of symptoms have resolved. Therefore relegating colonic hydrotherapy to only quiescent times may not be possible.
Also, it is not clear what impact colonic irrigation may have on scarred bowel or bowels in which a fistula has formed. A bowel fistula, incidentally, is the bowel’s attempt to redirect the course of the intestine. Fistulas may form that connect the bowel to the bladder, the vagina, another loop of intestine, or even the outside of the body. When this abnormal anatomy exists, it may be dangerous to infuse the rectum with large volumes of fluid.
Patients with Crohn’s disease are strongly encouraged to speak with primary care physicians and gastroenterologists about how to treat and manage this disease. There are a number of medical and (if needed) surgical interventions to control (but unfortunately not cure) Crohn’s disease. If you have Crohn’s disease and are considering hydrotherapy, high colonics, colonic irrigation, etc. talk to your doctor about the pros and cons in your specific situation. Do not be surprised if you are discouraged from using the colon cleansing technique. What will often be prescribed in its place is a high fiber diet (which is for some a colon cleansing approach) or an oral agent that will treat constipation/obstipation. Crohn’s disease is a difficult, life-long disease that needs to be managed thoughtfully, carefully, and effectively so that those suffering from it may lead the most fulfilling lives possible.
Ernst E. Colonic irrigation and the theory of autointoxication: A triumph of ignorance over science. J Clin Gastroenterol 1997 24;196-8.
O’Boyle CJ, MacFie J, Mitchell CJ, et al. Microbiology of bacterial translocation in humans. Gut. 1998 42;29 –35.
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