Colon Cleansing Gone Wrong EMRA
Gastroenterology
4/22/2020
Darren Cuthbert, MD, MPH
,
David Christopher Cuthbert, MD
,
Joshua Bucher, MD
Retained foreign bodies are not uncommon in emergency medicine, but this case presented unusual circumstances as the patient had consulted a Reiki master for a regimen of colon cleansing.
Case
A 52-year-old male with a past medical history of deep vein thrombosis on apixaban presented to the ED complaining of lower left quadrant abdominal pain, rectal pain, and a scant amount of bright red blood per rectum. The pain began approximately 1 day prior, shortly after a procedure he called colon hydrotherapy. The patient reported that multiple times over the course of the past year he has sought treatment from a holistic health center due to a health recommendation from his Reiki master. As a regular part of his therapy routine an acupuncturist would insert an aluminum tube into his rectum and spray pressurized water with the intention to improve overall gastrointestinal health. The pain was described as sharp, mostly in the left lower quadrant and rectum. The evening prior he felt the urge to defecate, but the pain was exacerbated upon pushing and he noticed bright red blood on tissue paper when cleaning. He decided to seek care in the morning as his pain was progressively worsening. A CT scan was obtained showing the following images.
Learning Points
A retained rectal foreign body is a complaint that emergency physicians will encounter multiple times throughout their careers.
In an urban population-based study, it was found that there is a patient encounter for a retained rectal foreign body at least once per month per hospital. Commonly encountered objects include bottles and glasses (42.2%), but the type of foreign body can vary widely. Patients are more frequently male and the average age at presentation is 44 years old. The reason people insert objects into their rectum is most often autoeroticism, concealment, attention seeking, or reported as accidental insertion. Patients with this presentation are often embarrassed so it is important to respect their privacy. During these patient encounters, providers may want to have a chaperone present at all times due to the psychological nature of this presentation. It is important to remember the potential that the object was placed involuntarily; always ask about the circumstances and offer help or counseling. On initial history taking, as was seen in this case, the patient may not endorse that there is a foreign body in their rectum up to 20% of the time.
The most common complaint is abdominal pain, rectal pain, constipation, obstipation, or bright red blood per rectum.
Once the foreign body is discovered through history or imaging, it is vital to repeatedly assess for peritonitis and hemodynamic instability as these situations require emergent surgical intervention. Removal of sharp objects should not be attempted within the ED due to the risk of perforation. If the patient is stable with limited risk factors, transanal extraction can be safely attempted within the emergency department. The patient should be placed in the lithotomy position and receive adequate amounts of analgesia. A perianal nerve block can be used if the object is not easily visualized or palpable. Extraction can proceed while using sufficient lubrication and asking the patient to assist using the Valsalva maneuver. Tools utilized for extraction vary widely depending upon type, shape, and depth of the object. Our first attempt was unsuccessful using a nasal speculum for retraction with ringed forceps to attempt grasping the object.
Colorectal surgery was consulted and used special anal retractors with Debakey forceps. Always observe for potential signs of instability secondary to surgical complications following extraction. Obtain a post-retrieval x-ray to rule out potential colorectal injury sustained during the procedure.
Regarding the patient’s colon irrigation, which is also referred to as colon hydrotherapy, or a “colonic,” there is currently no scientific evidence to support its use to promote gastrointestinal health. In contrast, there are serious potential risks. Patients often seek such modes of care in an attempt to cleanse their gastrointestinal system of harmful bacteria, or toxins. The procedure results in the disruption of the normal gastrointestinal flora, which is potentially harmful. There have been numerous case reports displaying the adverse events secondary to colon irrigation, ranging from abdominal pain, vomiting, nausea, diarrhea, bowel perforation, electrolyte imbalance, renal dysfunction, and, as seen in this case, retained rectal foreign bodies.
A systematic review published by the American Journal of Gastroenterology in 2009 concluded that there is no evidence to support colon hydrotherapy’s use to promote any form of health and recommended against this modality due to the risks listed above.
Case Resolution
This is not your typical rectal foreign body case, as the structure retained within the rectal cavity is not definitively known, the patient is anticoagulated, and he recently underwent a procedure that is not well known to most medical professionals. The patient was unable to initially tolerate a rectal examination due to the severity of pain. One attempt was made for retrieval after the foreign body was identified on CT scan. The patient was given 100 mcg of fentanyl beforehand to allow inspection, but the foreign body was not able to be visualized. Upon digital insertion, the patient again was unable to tolerate further examination due to pain. Colorectal surgery was consulted and the patient was taken to the operating room where he required high levels of sedation.
He was placed in the lithotomy position, underwent sedation, and 2 metal foreign bodies were retracted using Debakey forceps.
References
- Cologne KG, Ault GT. Rectal Foreign Bodies: What is the Current Standard? Clin Colon Rectal Surg. 2012;25(4):214-218.
- Dolgin E. Antidotes edge closer to reversing effects of new blood thinners. Nat Med. 2013;19(3):251.
- Haft JS, Benjamin HB. Foreign bodies in the rectum; some psychosexual aspects. Med Aspects Hum Sex. 1973;7:74-95.
- Gajjar RA, Gupta PB. Foreign body in the rectum: A challenge for the emergency physician. J Family Med Prim Care. 2016;5(2):495-497.
- Acosta RD, Cash BD. Clinical effects of colonic cleansing for general health promotion: a systematic review. Am J Gastroenterol. 2009;104(11):2830-2836.
Colon Cleanse FAQs: Risks, Benefits & More
CS-Blog
Cedars-Sinai Blog
Mar 22, 2019
Katie Rosenblum
Colon cleansing: Is it helpful or harmful?
Did you know that colorectal cancer is the third most commonly diagnosed cancer in men and women and second leading cause of cancer death in the US?
It’s important to take good care of your colon, the large intestine responsible for absorbing water and removing waste.
But how?
Maybe you’re thinking about trying a colon cleanse, also called colonic treatment, hydro colon therapy, colonic irrigation, or colon detox. These types of treatments are often advertised as a proactive approach to good colon health, but are there really medical benefits?
«Colon cleanses do not replace the need for regular screenings with your doctor.»
What is a colon cleanse?
Colon cleanses, which date back thousands of years, are usually done by a colonic hygienist.
During a colon cleanse, the hygienist inserts a tube into the rectum while you lie on a table.
A large amount of water is pushed through the tube to flush the colon. The water is then released through the colon in a way similar to a bowel movement.
What are the benefits?
Practitioners boast a variety of supposed health benefits, including removing toxins from the body, improving the immune system, helping with weight loss, improving digestion, boosting mood, and even reducing the risk of colon cancer.
But is there any truth to these claims?
«The presumed health benefits of these treatments are not proven,» says Dr. David Hoffman, medical oncologist at Cedars-Sinai Tower Hematology Oncology Medical Group.
«There are no established scientific benefits and in fact, there’s actually risk when doing these treatments in a non-medical setting.»
«There are no established scientific benefits and in fact, there’s actually risk when doing these treatments in a non-medical setting.»
What are the risks of a colon cleanse?
There are several risks to be aware of before you try a colon cleanse.
These risks include:
- Dehydration
- Infection from contaminated instruments or facilities
- Electrolyte imbalance in the colon
- Tears in the bowel
It’s also important to not confuse a colon cleanse with a colonoscopy screening, Dr. Hoffman says.
«Some people will mistakenly feel that doing a colonic is the equivalent to getting a coloscopy, and that is not the case,» says Dr.
Hoffman.
«Colon cleanses do not replace the need for regular screenings with your doctor.»
Read: Dodging a Colonoscopy?
Still want to try a colon cleanse?
Dr. Hoffman suggests talking to your doctor and making sure you know your unique risk.
«We understand that many patients like to try alternative treatments that complement their traditional healthcare,» Dr. Hoffman says.
«Speak to your doctor so you can understand your risk fully before seeking out this type of procedure.»
You should also do your research and choose a provider who is reputable and safe. You can reduce your risk of infection by ensuring that your hygienist uses only new, disposable equipment and wears proper protective gear.
Read: Lifestyle and Cancer: Understanding the Connection
What are some proven ways improve colon health?
Limit alcohol and red meat consumption, avoid tobacco, exercise at least 3 times a week, and see your doctor regularly for colonoscopies starting at age 45.
To help lower your risk of colon cancer and improve colon health, you can also eat more fiber. Several studies have linked a fiber-rich diet to reduced risk of colon cancer.
Ready to schedule your colonoscopy? Call 1-800-CEDARS-1 to make an appointment.
FORTRANS: an effective means for cleansing the intestines
In the digestive tract, there is an intensive exchange, absorption and release of biologically active substances, electrolytes, vitamins, amino acids, inactivation and elimination of toxic substances, etc. In case of violation of the detoxification function of the liver, as well as indigestion, toxic substances can be resorbed and enter the systemic circulation, adversely affecting various organs and systems. Digestive disorders and related symptoms were noted in 30–50% of adults (Rumyantsev V.G., 1997).
With these disorders, putrefactive and fermentation processes develop in the large intestine, which is accompanied by the formation of a large amount of toxic substances that adversely affect the body.
During the day, up to 5-6 liters of digestive juices are secreted into the digestive tract of a person, and only about 150 ml of liquid is excreted from the intestines. Digestive juices, saprophytic microorganisms and food create a special environment in the body, which is an important link (buffer) between the external and internal environment. An imbalance in this environment can lead to the development of a number of somatic diseases.
An unbalanced diet with a predominance of carbohydrate-rich foods in the diet enhances fermentation processes, which contributes to the formation of toxic substances. In addition, the intestinal lumen does not contain enzymes that can inactivate toxins. Therefore, substances such as heavy metals, herbicides, pesticides, various food additives (dyes, flavors) can slow down the detoxification and cleansing of the colon.
Currently, there are a large number of methods of bowel cleansing, among which should be noted cleansing enema, bowel irrigation, blind probing, taking special dietary supplements, etc.
These methods have a number of significant drawbacks. Thus, experience shows that with the help of a traditional cleansing enema, only the lower intestines are cleansed, which is 1/10 of its length. Setting an enema requires certain skills, and sometimes the participation of a second person. Bowel irrigation is an expensive procedure.
For several years, the French pharmaceutical company Bofur Ipsen has been supplying the Ukrainian market with a well-studied highly effective bowel cleanser FORTRANS (macrogol). The active substance of this drug is macrogol-4000, 64 g of which (1 sachet of FORTRANS) binds 1 liter of water. This property determines the mechanism of action of the drug. The molecule of the active substance — high molecular weight ethylene oxide — forms hydrogen bonds with water molecules. Thus, FORTRANS retains water in the intestinal lumen, due to which the entire volume of the macrogol solution taken is involved in intestinal lavage and, as a result, causes natural defecation.
The drug is not absorbed in the intestine, does not change the pH of the chyme, does not disturb the balance of electrolytes in the intestine, does not affect lipid metabolism, and acts regardless of the composition of the bacterial flora of the intestine. Experts recommend FORTRANS for oral cleansing (lavage) of the intestines. Taking 2–3 liters of a liquid containing FORTRANS according to the appropriate scheme ensures effective intestinal lavage. The use of the drug does not cause a burning sensation in the anus.
Initially, this drug was used to cleanse the intestines before surgery, endoscopic procedures, x-rays of the large intestine, etc. It turned out that it is well tolerated by patients, so now this drug is recommended for bowel cleansing, which can be done at home.
It should be noted that intestinal lavage with the help of FORTRANS is a non-invasive and relatively inexpensive procedure that allows you to equally effectively clean all parts of the intestine. Taking FORTRANS does not affect hemodynamic parameters, as well as the general well-being of patients (Nikiforov P.
A. et al., 1999). Taking FORTRANS is possible at home and does not require the participation of medical personnel, does not cause discomfort — pain in the abdomen, cramps and flatulence.
Contraindications to the use of FORTRANS are non-specific ulcerative colitis, Crohn’s disease, intestinal obstruction, abdominal pain of unknown etiology.
Simultaneous administration of macrogol and other drugs may reduce the absorption of the latter, and therefore it is recommended to take macrogol separately (with an interval of 2 hours).
To relieve constipation, Bofur Ipsen offers a preparation containing macrogol in lower doses (10 g), FORLAX. FORLAX is recommended to be taken during meals in the form of a drinking solution, for which 10 g of the powder is pre-mixed in 200 ml of water. It should be noted that in order to restore the sensitivity of the receptors of the intestinal mucosa, the course of treatment with FORLAX should be at least 2 weeks. A single dose of FORLAX has a temporary effect and does not lead to a long-term effect.
To date, macrogol has been found to be highly effective in the treatment of constipation of various etiologies. The drug is especially effective in patients with functional disorders of the digestive tract motility. Even in patients with decompensated liver cirrhosis, the use of FORLAX contributed to the normalization of stool and a decrease in the severity of symptoms of encephalopathy (Rudenko N.N. et al., 2000).
In a recent double-blind, multicenter clinical study of the efficacy of FORLAX in 256 patients with idiopathic constipation, its high efficacy was demonstrated (in 76.1% of cases) (Couturier D., 1996).
More detailed information about FORTRANS and FORLAX can be obtained by calling the «hot line» — (044) 293-41-55.
Based on materials provided by
representative office of
Bofur Ipsen in Ukraine
Colonoscopy in the diagnosis of diseases of the large intestine
Colonoscopy (derived from Latin colon — large intestine and Greek σκοπέω — look) is a diagnostic medical procedure during which an endoscopist examines and evaluates the condition of the inner surface of the large intestine using a special tool — an endoscope (colonoscope).
Modern equipment allows colonoscopy to detect changes in the mucous membrane of even small sizes in the intestine. The therapeutic possibilities of our department and the qualifications of our specialists allow us to remove polyps of any size without complications — from 1 millimeter to 8-10 cm giant polyps. Immediately after the removal of the polyp, it can be examined and determined whether it is absolutely benign or has already begun to degenerate into cancer.
The words endoscope and colonoscope are synonyms. A colonoscope is a flexible endoscopic instrument in the form of a narrow flexible tube, specially designed for viewing the colon, it is slightly longer than a gastroscope (a device for examining the stomach) and slightly thicker. At the end of the colonoscope is a video camera and lighting. The tip of the device is flexible and movable; the doctor controls it from the handle using a system of levers and rods located inside the endoscope.
This examination method allows visualization of the entire large intestine, including the terminal small intestine.
Various diseases of the intestine, colon cancer, rectal cancer, polyps in the intestine — this is just an incomplete list of the most common reasons to perform a study of the colon — colonoscopy.
If the doctor finds polyps during the procedure, they can remove them immediately or take tissue samples for further histological analysis. Also, in the process of endoscopic examination, the doctor can indirectly assess the functional activity of the intestine.
In addition, colonoscopy is performed to remove early forms of cancer, to identify and eliminate the focus of bleeding, and to remove foreign bodies.
Local anesthetic ointments and gels are used to reduce discomfort. The procedure is carried out on the most modern equipment from Olympus (Japan).
How to prepare for a colonoscopy.
The success and informativeness of the study is determined mainly by the quality of the preparation for the procedure, so pay the most serious attention to the implementation of the preparation recommendations.
Remember, in order for the doctor to be able to examine the mucous membrane of the large intestine in detail and carefully, it is necessary that there are not even traces of feces in its lumen.
Proper and thorough preparation of the bowel for examination facilitates a thorough examination and leads to a correct diagnosis.
Below are recommendations on how to properly prepare for an endoscopic examination of the colon — conoscopy and schemes for preparing for an endoscopic examination of the intestine.
You can choose any of 4 preparations:
- Fortrans
- Fleet Phospho-soda
- Lavacol
- Pikoprep
- Moviprep
When using the above preparations, enemas are not necessary!
Once again we remind you of the need to exclude any vegetables 3 days before the examination (you can only have a few boiled potatoes without peel, you can also mousse / i.e. punched in a blender / from ½ banana) and fruits, black bread (especially grain), nuts, cereals (you can only rice).
General recommendations on diet and regimen:
On the day of preparation (i.e. the day before the study) a light breakfast — tea / coffee / juice + white bread, butter + low-fat cottage cheese / yogurt without additives, you can eat at lunch broth “empty” or with vermicelli, boiled meat, fish, chicken, cheese, white bread, butter, cookies, yogurt without additives, then the actual preparation. Lunch no later than 2 hours before the start of training. On the day of preparation, the intake of clear liquids (including juices without pulp) is not limited both before, during and after preparation. If you suffer from constipation, it is necessary to take laxatives that you usually use every day. You can even slightly increase their dose. You do not need to sit in front of a glass of liquid for preparation — if your state of health allows, move between drinks, walk around, periodically performing simple gymnastic exercises such as «charging» (tilts, stretching, raising your arms up, squats, body rotations, etc.
). If you have already prepared one of the preparations before and the doctor said during the study that the preparation is good, prepare according to the same scheme with the same preparation — there is no need to experiment.
*******
drug «Fortrans»
1 Fortrans® bag in 1 liter of water, take 1 liter of solution for 1 hour (respectively 3 or 4 hours, depending on from the number of packages required for your weight), about 1 glass in 15 minutes. One pharmacy pack of FORTRANS contains 4 sachets.
For patient weights up to 70 kg, 3 sachets are used; for larger patient weights, all 4 sachets must be used. Use water at room temperature to prepare the solution (do not use sparkling water). To improve the taste, you can drink sour juice without pulp. If you experience nausea while taking FORTRANS, stop taking the drug for half an hour. After 1-2 hours from the start of taking the drug, you will have loose stools, bowel movement will be completed 1-2 hours after the last dose of FORTRANS.
If it seems to you that bowel cleansing was insufficient after 3 packets, use the 4th one or drink an additional 1 liter of any clear liquid (min. drink water without gas). In most cases, taking 4 liters of FORTRANS is a guarantee of good bowel preparation for colonoscopy.
The optimal time to start preparation is 16.00-17.00 on the day before the procedure.
When using Fortrans® on the day of the study, it is also not necessary to do enemas!
*******
Fleet Phospho-Soda
7:00 am 7 a.m. Instead of breakfast, drink at least 1 glass of light liquids (water or filtered meat broths, fruit juices without pulp (except red or purple juices), tea or coffee without milk, non-carbonated refreshing drinks). Immediately after this, dissolve the contents of 1 bottle of Fleet Phospho-soda (45 ml) in half a glass (120 ml) of cool water. Ready solution to drink and drink 2 glasses (500 ml) of cool water.
13:00 At 13:00, drink at least 4 glasses (1 L) of light, clear liquid instead of lunch.
19:00 At 19:00, drink at least 2 glasses of light liquid instead of dinner. Immediately after this, dissolve the contents of 1 bottle of Fleet Phospho-soda in half a glass (120 ml) of cool water. Drink the prepared solution and drink it with 1 glass of cool water, and then drink another 1 liter of water within 1 hour. If desired, you can drink more liquid. Light liquids can be drunk without restriction until midnight.
If the colonoscopy is scheduled for the afternoon (after 12 noon) and will be performed without anesthesia.
The day before the test 13:00 At 13:00 you can have a light snack during lunch. After dinner, no solid food should be eaten. 19:00 At 19:00 instead of dinner, you should drink 2 glasses of light liquid (water or filtered meat broths, fruit juices without pulp (except for red or purple juices), tea or coffee without milk, non-carbonated refreshing natki). Immediately after this, dissolve the contents of 1 bottle of Fleet Phospho-soda in half a glass (120 ml) of cool water.