The Science Behind Enemas

There has been a lot of discussion about the use of enemas to treat various gut issues. I thought it was time to go over the science behind the subject. This article ends with abstracts from a number of studies.

When I wrote the book “The Gut Health Protocol” I decided to include only the natural treatments that had good evidence of efficacy and safety. I didn’t totally ignore established medical advice, but my focus was on scientific studies, many (if not most) of which were major university studies, peer reviewed, with good study methodologies. I certainly did not overlook anecdotal evidence, in fact I read hundreds (if not thousands) of reviews on Amazon, Vitacost, Swanson Vitamins, etc.  Reviews of more supplements than I care to remember. I also read through many forums on the subject. In some cases the only evidence available is anecdotal because no studies have been run yet. But my “gold standard” was on a well run, independent, scientific study. I’m very open minded about almost everything in life, I just want to see the evidence.

One of the natural alternative medicine treatments that some people like to use is an enema (also known as a clyster, high colonic, colonics, colonic irrigation, colon hydrotherapy, and colon cleansing). Judging from all of the testimonials I’ve heard from people, and read online, I think many people do feel better for a day or two after doing one. Especially those people suffering from chronic constipation. However, there is no scientific evidence that enemas help any medical condition other than a bowel obstruction and temporary relief from constipation. In fact there is quite a bit of research on the harms and risks associated with enemas, especially from frequent use.

An enema usually uses warm tap water, sometimes mixed with coffee, enzymes, herbs, teas, fibers, magnesium oxide, licorice, probiotics, aloe, soaps, etc. Often times what is perfectly fine to consume orally, can cause unwanted side effects when taken as colonic. For instance there have been many reports of people over caffeinating themselves from a coffee colonic, causing rapid heart rate, jitters, nausea, heart palpitations, anxiety, etc.  The coffee or tea that you use may contain pesticides or fertilizers. Even if the products are “organic” they can contain “natural” analogs that can be harmful to the colon, your health, or to your microbiome. Probiotic pills contain fillers, magnesium stearate, flow agents, and other unwanted synthetic ingredients commonly used to reduce manufacturing costs. Even the tap water that you use may contain small amounts of organic compounds that get broken down into harmless components in the stomach but are not good for the delicate lining of the colon. The use of chlorinated tap water applied in the colon will likely kill good bacteria and may, over time, cause damage to the sensitive colon wall and the mucosal lining. All of this may lead to Crohn’s Disease, colitis or another Inflammatory Bowel Disease or Irritable Bowel Syndrome.

Electrolyte imbalances from frequent use of colon cleansing is common, especially from coffee enemas. This can lead to dehydration, heart attack and even death. More commonly people can develop a dependency to enemas and are unable to defecate normally without them. This can lead to complications and withdrawal symptoms when one stops using enemas to defecate.

Even worse many people self-medicate with enemas for problems that have little, or nothing, to do with the colon, such as: problems in the stomach from an ulcer or an h.pylori infection, Small Intestinal Bacterial Overgrowth (SIBO), or a small intestinal candida overgrowth will not be helped by an enema. The ileocecal valve, located between the small intestine and the colon, will block enema fluids from reaching the small intestine (which is a very good thing, otherwise you will simply be washing fecal matter and colonic bacteria in the small intestine).

The use of probiotics in an enema sounds useful on the surface. After all the goal should be to restore the intestinal microbiota to a healthy state and what could be better than a direct application of probiotics. However, this is a misguided approach.

“Humans evolved in the presence of numerous microbial communities that preceded the appearance of mammals on planet Earth. The role of these microbial communities in our evolution is a matter of considerable interest. Indeed, comparative studies with germfree and conventional animals have established that the intestinal microflora is essential for the development and function of the mucosal immune system during early life, a process that is now known to be important to overall immunity in adults. An absence of intestinal bacteria is associated with reductions in mucosal cell turnover, vascularity, muscle wall thickness, motility, baseline cytokine production, and digestive enzyme activity and with defective cell-mediated immunity (83). Furthermore, the intestinal microflora makes important metabolic contributions to vitamin K, folate, and short-chain fatty acids, such as butyrate, a major energy source for enterocytes, and also mediates the breakdown of dietary carcinogens…  Resident bacteria serve a central line of resistance to colonization by exogenous microbes and thus assist in preventing the potential invasion of the intestinal mucosa by an incoming pathogen.”  — From the journal American Society for Microbiology

“The new study found that the bacteria community of the colon was even more diverse than ever imagined, turning up at least 5,600 separate species or strains.”  — LiveScience

Below is a list of the most common bacteria normally found in the colon, see how many of these are listed on your bottle of probiotics before you decide to use them in an enema. The reason for taking probiotics orally is to create an environment for your normal microbiota to flourish, they can not directly replace your native flora. This is done in large part by the lactic acid (and other compounds) these transient strains produce as a by product. Washing out your native bacteria and replacing it with relatively very small amounts of lactic acid bacteria is not helpful. You would be far better off consuming a serving or two of sauerkraut each day (one 3 ounce serving has more bacteria than your whole bottle of probiotic pills), it would also benefit your small intestine.

Below are but a few excerpts from some of the research studies I reviewed, and the reason why I would not recommend enemas for gut health:

“frequent use of high-volume tap-water enemas may lead to substantial electrolyte disturbances and should be avoided” — PubMed #PMC2755809

“Perforation, hyperphosphatemia (after Fleet Enema (phospho-soda)), and sepsis may cause death in up to 4% of cases. Guidelines for the treatment of acute constipation and for enema administration are urgently needed…Enemas can be very effective but may cause serious adverse events, such as perforation or metabolic derangement. Hypertonic sodium phosphate enemas (such as that commonly found in pharmacies) may cause severe phosphate nephropathy… In conclusion, enema for the treatment of acute constipation is not without adverse events, especially in the elderly, and should be applied carefully. Perforation, hyperphosphatemia (after Fleet Enema), and sepsis may occur, causing death in up to 4% of cases. National guidelines for the treatment of acute constipation and for enema administration are urgently needed.” — PubMed #PMC3641812

“Severe anaphylactic reaction after a soap enema…described a case of rectal gangrene in a patient who received two successive soap enemata, and a case of severe haemorrhageis reported from Minneapolis…Repeated soap enemata may cause mucosal damage, particularly if a portion of the first enema is retained. Introduction of the enema fluid under high pressure is hazardous as the haemorrhoidal venous plexus may be entered” — PubMed #PMC1748582

“Herbal enema: At the cost of colon…Various colonic side-effects of herbal enema have been reported in literature ranging from mild abdominal discomfort to self-limiting haemorrhagic colitis. It rarely requires blood transfusion or subtotal colectomy… complication of herbal enema in the form of severe ileo-colitis with persistent massive lower gastrointestinal bleed immediately after administration of enema for the treatment of chronic constipation…Contrary to the widespread belief that because it is natural it is safe, herbal therapy probably carries major risks and produces more serious side-effects than any other form of alternative medicine… The injurious side-effects of herbal enema vary from mild abdominal discomfort and self-resolving haemorrhagic proctocolitis to severe colitis. ” — PubMed #PMC3401717

“Enemas are commonly used in medical practice, and the soap enema has been adopted for routine use by many obstetric units. Several adverse reactions associated with soap enemas have been well documented” — PubMed #5087724

“A 5-year-old boy developed acute colitis followed by stricture formation as a result of a detergent enema.” — PubMed #927976

“A patient had severe colitis after soap enemas for five days. Elimination of the soap enemas resulted in resolution of the colitis. We suggest that soap enemas be avoided.” — PubMed #3775481

“Polarized intestinal epithelial cells (IEC), as well as the resident microflora, provide a barrier that guards against microbial invasion (Fig. 1). The necessity for the epithelium to maintain an intact barrier between lumen bacteria and the lamina propria is exemplified by the consequences after the barrier function is altered. Indeed, impairment of the barrier function of the intestinal epithelium may be a predominant mechanism in the pathogenesis of inflammatory bowel disease (IBD)”  — From the journal American Society for Microbiology  Frequent enemas, or incorrectly administered enemas, can damage this this thin layer of epithelial cells and the intestinal mucosa.

“Enemas have been used for hundreds of years in a variety of forms, including water, soapsuds, phosphate and sugar solutions. In spite of this long history, there is only anecdotal evidence for their value in the management of CC (chronic constipation)… enemas should be used with caution in patients with impaired renal dysfunction, pre-existing electrolyte imbalances, risk of electrolyte disturbance (hypocalcemia, hyperphosphatemia or hypernatremia) or a serious adverse event secondary to one of the above, dehydration, chronic inflammatory bowel disease, gastric bypass or stapling surgery. Because of their adverse irritating effect, soapsud enemas should be avoided…. Long-term use of stimulant laxatives (oral or suppositories) and/or enemas should be avoided. — PubMed #PMC2794454

Osmotic diarrhea (such as that from certain laxatives) works the same way as enemas, they draw water into the colon to help expel the contents. “Stool and mucosal microbiotas were strikingly different, with Firmicutes dominating the mucosa and Bacteroidetes the stools. Osmotic diarrhea decreased phylotype richness and showed a strong tendency to equalize the otherwise individualized microbiotas on the mucosa. Moreover, diarrhea led to significant relative shifts in the phyla Bacteroidetes and Firmicutes and to a relative increase in the abundance of Proteobacteria on the mucosa, a phenomenon also noted in several inflammatory and diarrheal GI diseases.” — PubMed #PMC3568139

There is even a possibility of contracting a clostridium difficile infection after an emema. Though not common, it can’t be ruled out. “C. difficile colonizes the human intestinal tract after the normal gut flora has been altered”. An enema has been proven to dramatically alter the colon’s microbiota.

Enemas wash out and disrupt the microbiota in the colon without differentiating; good, bad, and indifferent strains are all flushed out. This leaves the colon open to infection (much like after antibiotics). The following is from my book The Gut Health Protocol:

“Think of it this way. What would happen if you had a nice lawn of grass and you decided to completely poison it (or power wash all the grass away), just to see what would grow back if you did nothing to it? The odds of having just beautiful grass and flowers grow back is exceedingly remote, chances are you would get mostly weeds. In this case you are likely to get strong pathogenic bacteria and yeast grow back.”

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