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Colon Hydrotherapy an Update COLON HYDROTHERAPY AN UPDATE HEALTH TECHNOLOGY ASSESSMENT SECTION MEDICAL DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA 012/2009 i DISCLAIMER Technology review is a brief report, prepared on an urgent basis, which draws on restricted reviews from analysis of pertinent literature, on expert opinion and / or regulatory status where appropriate. It is subjected to an external review process. While effort has been made to do so, this document may not fully reflect all scientific research available. Additionally, other relevant scientific findings may have been reported since completion of this review. Please contact: [email protected], if you would like further information. Health Technology Assessment Section (MaHTAS), Medical Development Division Ministry of Health Malaysia Level 4, Block E1, Precinct 1 Government Office Complex 62590 Putrajaya Tel: 603 88831246 Fax: 603 8883 1230 Available at the following website: http://www.moh.gov.my ii Prepared by: Dr Junainah Sabirin Principal Assistant Director Health Technology Assessment Section (MaHTAS) Ministry of Health Malaysia En Sahaludin Sharif Assistant Medical Officer Health Technology Assessment Section (MaHTAS) Ministry of Health Reviewed by: Datin Dr Rugayah Bakri Deputy Director Health Technology Assessment Section (MaHTAS) Ministry of Health Malaysia External reviewer: Dr Wan Khamizar Wan Khazim Consultant Colorectal Surgeon Hospital Sultanah Bahiyah Alor Setar, Kedah DISCLOSURE The authors of this report have no competing interest in this subject and the preparation of this report is totally funded by the Ministry of Health, Malaysia iii EXECUTIVE SUMMARY Introduction Colon cleansing (colon therapy) encompasses a number of alternative medical therapies intended to remove faecal waste and unidentified toxins from the colon and the intestinal tract. Colon cleansing may take the form of colon hydrotherapy (also called colonics or colonic irrigation) or oral cleansing regimens. Colon hydrotherapy uses enemas to inject water, sometimes mixed with herbs or other liquids, into the colon using special equipment. Oral cleansing uses dietary fibre, herbs, dietary supplements or laxatives. Practitioners believe colon cleansing removes accumulation of faeces from the walls of the large intestine which are believed to putrefy, harbour parasites or pathogenic gut flora to cause non specific symptoms and general ill-health (referred to as “autointoxication”). This hypothesis is based on medical beliefs of the Ancient Egyptians and Greeks. Objective /aim To assess the safety, effectiveness and cost-effectiveness of colon hydrotherapy for body detoxification, constipation, irritable bowel syndrome and diverticulosis. Results and conclusions The search strategies yielded 2 articles concerning the U.S. Food and Drug Administration (FDA) premarket notifications for devices used in colon cleansing and one article issued by the Texas Attorney General. There were seven articles (case series / case report/cross sectional studies) related to the adverse events of colon hydrotherapy. As for the effectiveness, one technology review and three cross sectional studies were retrieved. In the United States of America the treatments are approved by the FDA for patients only when medically indicated, such as prior to undergoing radiologic or endoscopic examination. There was poor level of evidence to suggest that commercial colonic hydrotherapy performed by individuals themselves or by alternative medicine practitioners may lead to adverse events such as colon or rectal perforations, abscess, perineal gangrene, abdominal pain, abdominal cramps, distended abdomen, rectal bleeding, outbreaks such as amebiasis and death. There was also poor level and insufficient evidence to suggest the effectiveness of colon hydrotherapy for constipation, irritable bowel syndrome and faecal incontinence. There was no retrievable evidence on the cost-effectiveness of colon hydrotherapy. Colon hydrotherapy should be performed by experienced and trained practitioners. The practice should be regulated. Recommendation Based on the above review, more high quality clinical research is warranted for various application of this technology in different conditions such as constipation, irritable bowel syndrome and faecal incontinence. Hence, commercial use of colon hydrotherapy when iv not medically indicated cannot be recommended until more high quality evidence is available. Methods Electronic databases which included PubMed, Ovid Medliner from 1950 to May week 2 2009, EBM Reviews-Cochrane Central Register of Controlled Trials, EBM Reviews- Cochrane database of systematic reviews, EBM Reviews-HTA Databases, Horizon Scanning database (Euro scan, Australia and New Zealand Horizon Scanning, defra), FDA website, MHRA, and Google were searched for published reports. There was no limit in the search. Relevant articles were critically appraised using Critical Appraisal Skills Programme (CASP) and evidence graded using US / Canadian Preventive Services Task Force. v COLON HYDROTHERAPY AN UPDATE 1. INTRODUCTION The colon is the last portion of the digestive system in most vertebrates. In mammals the colon consists of four sections: the ascending colon, the transverse colon, the descending colon and the sigmoid colon. The colon measures approximately 1.5 meters in length. It is mainly responsible for storing waste, reclaiming water, maintaining the water balance and absorbing some vitamins, such as vitamin K.1 Colon cleansing (colon therapy) encompasses a number of alternative medical therapies intended to remove faecal waste and unidentified toxins from the colon and the intestinal tract. Colon cleansing may take the form of colon hydrotherapy (also called colonics or colonic irrigation) or oral cleansing regimens.2 Colon hydrotherapy uses enemas to inject water, sometimes mixed with herbs or other liquids, into the colon using special equipment. Oral cleansing uses dietary fibre, herbs, dietary supplements or laxatives. Practitioners believe colon cleansing removes accumulation of faeces from the walls of the large intestine which are believed to putrefy, harbour parasites or pathogenic gut flora to cause non specific symptoms and general ill-health (referred to as “autointoxication”). This hypothesis is based on medical beliefs of the Ancient Egyptians and Greeks.2 Colon hydrotherapy or colonic irrigation has its roots in ancient Egypt, Greece and India and has been used in Western world since the 1800s. It has formed an important part of traditional medicine. An individual may either choose to perform the colonic treatment on his own by purchasing a home colonic kit, or he may go to a colon hydrotherapy clinics. Treatments are usually given in a clinic or spa and sessions lasts 30 to 50 minutes. Practitioners should be qualified and a member of a recognised professional association such as International Association for Colon Hydrotherapy (I-ACT), Australian Colon Hydrotherapy Association (ACHA) in Australia or Association and Register of Colon Hydrotherapists (ARCH) in the United Kingdom (U.K.).3 Rectal irrigation also known as trans-anal irrigation is a way of emptying the lower bowel. It has been found to empty stool as far up as the splenic flexure. In the U.K., it must be prescribed and conducted by medically trained personnel. Indications of use are such as in neurogenic bowel disfunction; for example spinal cord injury, spina bifida and multiple sclerosis. It is also indicated for chronic constipation and chronic faecal incontinence.4 This technology review was conducted following a request from the Director of Kampar Hospital, Perak. 2. OBJECTIVE /AIM 6 The objective of this systematic review was to assess the safety, effectiveness and cost- effectiveness of colon hydrotherapy for use in conditions such as constipation, irritable bowel syndrome, diverticulosis and body detoxification. 3. TECHNICAL FEATURES Colon Hydrotherapy Colonic treatment is now used in the U.K. as a naturopathic modality and it is claimed to be useful in treating:- Primary bowel conditions such as Irritable Bowel Syndrome (IBS) and constipation where the bowel can be normalised through the water temperature variation during treatment Some organic disease states such as diverticulosis (diverticulitis in remission) where regular elimination is important. Bowel transit time is improved Many secondary conditions, especially those affecting the other eliminative organs (skin, urinary tract and lungs) where they are accompanied by poor bowel mechanics Body detoxification, when it is accompanied by dietary measures5 It was claimed that the benefits of colonic irrigation through colon hydrotherapy can often be quickly observed in the form of improved bowel function together with clearer skin, more mental clarity and fewer headaches.5 There is no special preparation needed before the colonic treatment, although large meals and lots of fluids are not advised. The first appointment includes history taking, explaining the procedure and the treatment itself. A brief rectal examination must be carried out followed by an introduction of a speculum 1.5 inches (4 cm) is introduced to open the sphincter. An inlet and outlet tube is attached to the outside of the speculum, to open the system, with water going in and waste out. The waste is piped away. About 60 litres of water are used per treatment, but only small amounts are allowed to enter the bowel at any one time, acting to dilate the lower bowel, stimulating the bowel to empty itself. In all, about 15 litres
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