Dr. Sylvester Yong’s 2011 Scientific Workshop
Colonic Irrigation: A Useful Alternative in Management of Constipation
A Therapeutic Challenge
- Increasing prevalence with age
- Variable presentation
- Multiple Causes
- Multiple + Associeted Symptoms
- Adversely affect Quality of Life
- May Impact Survival
Constipation Patho-Physiology
Dry Impacted Stool ~ Slow Transit ~ Colonic Inertia
SYMPTOMS
- Straining
- Irregular/Incomplete Bowel Movement
- Associated symptoms Boating/Gas
FEATURES COMMON TO
- Constipation
- IBS – C
- Functional Bowel Disorders
- Bowel Related Diseases
Colonic Irrigation
Dry Impacted Stool ~ Slow Transit ~ Colonic Inertia
SYMPTOMS
HYDRATION ~ ACTIVATION ~ EVACUATION
Therapeutic Potential
- Constipation
- IBS – C
- Functional Bowel Disorders
- Bowel Related Diseases
Colon Irrigation Efficacy
Mode of Action
Procedure infuses water into the colon
HYDRATION
soften & loosen DRY IMPACTED STOOL
ACTIVATION
improved TRANSIT/PERSTALSIS
EVACUATION
initiate BOWEL MOVEMENT
Christensen P, et al. Dis Colon Rectum. 2003 Jan;46(1):68-76. Scientific assessment of retrograde colonic washout in fecal Incontinence & constipation.
Colonic Irrigation Safety
Instrument Safety
- Water purity
- Controls: Temp/Pressure/Flow
- Use of Disposable
- Built-in Disinfecting system
Procedure Safety
- Trained therapists
- Protocols
- Supervision
Long term safety
- Results from studies using various irrigation techniques
Christensen P, et al. Dis Colon Rectum. 2003 Jan;46(1):68-76. Scientific assessment of retrograde colonic washout in fecal Incontinence & constipation.
Faaborg PM, et al. Colorectal Dis. 2010 Jan. Anorectal function after long-term transanal colonic irrigation.
Colonic Irrigation Evidence
Studies indicating benefits:
- Gardiner A, et al. Nurs Stand. 2004 Nov 10-16; 19(9):39-42.
Rectal irrigation for relief of functional bowel disorders. - Tod AM, et al. Br J Nurs. 2007 Jul 26-Aug 8;16(14):858-64.
Rectal irrigation in the management of functional bowel disorders: a review - McWilliams D. Nurs Standard. 2010 Mar 3-9;24(26):42-7.
Rectal irrigation for patients with functional bowel disorders. - Koch SM, et al. Int J Colorectal Dis. 2009 Sep;24(9):1019-22.
Retrograde colonic irrigation for faecal incontinence after low anterior resection
Constipation – Management Goals
Bowel Movement
- Clinical improvement
- Less use of laxatives
Relief of Symptoms
- Straining/Hard stools
- Incomplete evacuation
- Abdomen discomfort
Address Patho-psysiology
- Hydration
- Contraction
- Evacuation
Improved QoL
- Relief from chronicity
- Improved daily activities
Summary
Constipation remains a challenging problem. Current management options remain unsatisfactory especially in chronic cases. Colon irrigation is a simple and useful procedure that addresses the patho-physiology underlying constipation. Clinical studies to define its therapeutic potential in the management of constipation should be encouraged.
Journal of Gastroenterology & Hepatology
Vol 25 Suppl 2 – Sep 2010
ISSN: 0815-9319
Pg 82 Ref 319
Colonic Irrigation: a useful alternative in management of constipation (Abstract)
The management of constipation remains a challenge in clinical practice. Prescription medicine such as the use of laxatives and bulking agents offers some level of relief but are not always effective. Treatment options in chronic cases include biofeedback therapy, colonic lavage and manual evacuation. These too offer only limited and unsatisfactory results (1).
Colonic irrigation using different approaches have been demonstrated to be useful in the treatment of functional constipation (2) (3) (4) and various bowel related problems (5) (9). The procedure infuses water into the colon to facilitate the evacuation of bowel contents. Water hydrates (soften and loosen) bowel contents and activates peristaltic activity resulting in spontaneous bowel movement and evacuation of bowel contents. Although not regularly recommended, studies have demonstrated the beneficial effects of colonic washout in the treatment of constipation and faecal incontinence (6) (7) (8).
With the availability of modern instruments incorporating safety designs that meets F.D.A. guidelines, a more serious look at colonic irrigation as a useful alternative in management of constipation should be considered. Design of instrument also provide for the observation of the discharging waste and offers a more objective means of assessing the outcome of therapy.
In this paper, the results of patients suffering from chronic constipation who have not responded satisfactorily to conventional therapy and had colonic irrigation carried out on them are reported. In the majority of cases, symptomatic relief and improvement were noted. Details of the procedure and the rationale for recommending the procedure will be discussed.
Conclusion: Colonic irrigation can be a useful alternative in the management of constipation. It is a simple procedure yet its therapeutic potential remains unexplored. Clinical studies should be undertaken to ascertain the safety and efficacy of the procedure and to consider its use as an alternative option in the management of constipation.
References:
(1) J. F. Johanson; J. Kralstein. Alimentary Pharmacology & Therapeutics. 2007; Pg 25(5):599-608. Chronic Constipation: A Survey of the Patient Perspective
(2) Gardiner A, Marshall J, Duthie G. Nurs Stand. 2004 Nov 10-16;19(9):39-42. Rectal irrigation for relief of functional bowel disorders
(3) Tod AM, et al. Br J Nurs. 2007 Jul 26-Aug 8;16(14):858-64. Rectal irrigation in the management of functional bowel disorders: a review
(4) McWilliams D. Nurs Standard. 2010 Mar 3-9;24(26):42-7. Rectal irrigation for patients with functional bowel disorders.
(5) Koch SM, et al. Int J Colorectal Dis. 2009 Sep;24(9):1019-22. Retrograde colonic irrigation for faecal incontinence after low anterior resection
(6) Christensen P, et al. Dis Colon Rectum. 2009 Feb; 52(2):286-92. Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence.
(7) Faaborg PM, et al. Colorectal Dis. 2010 Jan. Anorectal function after long-term transanal colonic irrigation.
(8) Christensen P, et al. Dis Colon Rectum. 2003 Jan;46(1):68-76. Scientific assessment of retrograde colonic washout in fecal Incontinence & constipation.
(9) Sacha M. Koch et al. Colonic irrigation for defecation disorders after dynamic disorders after dynamic graciloplasty Int J Colorectal Dis (2008) 32:195-200
CONSTIPATION
A common yet challenging problem
- One of the most common GI conditions
- High prevalence
- Elderly prevalence of up to 50%
- Rx remain unsatisfactory especially in Chronic Constipation
- Negative impact on QoL
- Impact on survival
J. F. Johanson; J. Kralstein. Alimentary Pharmacology & Therapeutics. 2007; Pg 25(5):599-608. Chronic Constipation: A Survey of the Patient Perspective
Constipation Causes
Constipation type
Many causes identified as IDIOPATHIC
Colonic inertia (slow transit) 75%
- Dysfunctional neuromusc coordination
- Chronic use of laxatives
- Part of generalized disorder
Functional outlet obstruction
- Intrarectal intussuception
- Perineal descent
- Spastic pelvic floor (anismus)
IBS-Constipation predominant
**Treatment options vary with type of constipation**
Constipation Presentation
Symptom
obvious to patient, may not be bothersome
Problem
may not be obvious to patient, may be considered as not important
Disease
causes discomfort/need relief
Clinical Picture
Variable symptoms
- Infrequent/Irregular
- difficult/incomplete bowel movements
- hard stool/pellet
Associated complaints
- Discomfort
- Bloatedness
- Distension
- Pain
Variable Clinical Picture
Onset type
- Acute
- intermittent
- chronic
- Acute on Chronic
Severity
- mild
- Severe (protracted)
Patho-physiology
- Normal transit
- Slow transit
- Pelvic for dyssynergia
Drug/Disease related
Constipation Morbidity
- Distress
- Discomfort
- Dissatisfaction with Rx
- Decreased Quality of Life
- Decreased Survival
Management issues – to address
Primary problem
Constipation
Associated problems
Discomfort, Distension, Gas, Functional problems, Parasites, Yeast, Food intolerance, Flora imbalance, Intestinal permeability, Systemic problem
Contributing factors
Habits, Exercise, Medication, Dentition, Water intake, Fiber intake, Eating habits, Stress
Management Options
Laxatives | Biofeedback
Colonic lavage | Manual evacuation | Surgery
Management Issues
- Rx Unsatisfactory
- Limited Efficacy
- Does not address underlying cause
- Varying severity of problem
- No objective assessment tool
Laxatives
- Cornerstone of Rx
- Important to understand why it is useful
Management Goals
- Symptomatic relief: *Constipation*Associated symptoms*
- Induce bowel movement
- Improved bowel function
- Avoid complication/disease/surgery
- Reduced medication
- Improved QoL
- Reduced morbidity
- Reduced co-morbidity eg. Cancer, death
Colon Irrigation
A Useful Option
- Description
- History
- Potential effects in improving constipation
- Mode of action
- Safety issues
Colon Irrigation
- Different techniques
- Rx of functional constipation
- Rx of bowel related problems
- Rx of constipation and feacal incontinence
- Bowel prep for Colonoscopy/Surgery
Gardiner A, et al. Nurs Stand. 2004 Nov 10-16; 19(9):39-42.
Rectal irrigation for relief of functional bowel disorders.
Tod AM, et al. Br J Nurs. 2007 Jul 26-Aug 8;16(14):858-64.
Rectal irrigation in the management of functional bowel disorders: a review
McWilliams D. Nurs Standard. 2010 Mar 3-9;24(26):42-7.
Rectal irrigation for patients with functional bowel disorders.
Koch SM, et al. Int J Colorectal Dis. 2009 Sep;24(9):1019-22.
Retrograde colonic irrigation for faecal incontinence after low anterior resection
Colon irrigation, also called colon hydrotherapy…
is a variant of enema treatment, which involves flushing of the bowel with water in different quantities, temperature and pressures. Through a tube inserted via the rectum, water may be introduced alone or with added enzymes, coffee, probiotics, or herbs. Treatment sessions usually last about an hour. During a “high colonic,” water goes in through one tube in the colon and is removed along with debris through another tube called an obturator.
Extract from a monograph prepared by professional staff at Natural Standard, based on systematic review of scientific evidence. The material was reviewed by the Faculty of Harvard Medical School.Christensen P, et al. Dis Colon Rectum. 2003 Jan;46(1):68-76. Scientific assessment of retrograde colonic washout in fecal Incontinence & constipation.
Potential Benefits
- Assist with bowel movement
- Symptomatic relief
- Lesser use of laxatives
- Improve Quality of Life
- Others
Procedure Benefits
Cleansing
- Immediate relief
- On-going maintenance/prevention
Education
- Prevent (avoid) problem/symptoms
- Improve function
- Improve health & wellbeing
- Improved Quality of Life
Colon Irrigation Concerns
Evidence of Efficacy
Evidence of Safety
E. Ernst Int Clin Pract. 2010;64(4):429-431.2010 Colonic Irrigation: Therapeutic Claims by Professional Organisations, a Review
Instrument Safety
FDA Registered Instrument
Water quality
Controls: Temperature/pressure/flow
Hygiene & Sanitation
Procedure Safety
Qualification
Training standards
Adherence to medical guidelines
Following medical protocol
Long Term Safety
Christensen P, et al. Dis Colon Rectum. 2009 Feb; 52(2):286-92. Long-term outcome and safety of transanal irrigation for constipation and fecal incontinence.
Faaborg PM, et al. Colorectal Dis. 2010 Jan. Anorectal function after long-term transanal colonic irrigation.
Securing Evidence to support Colon Irrigation remains a challenge
Opportunities exist because…
- Limited options of Rx of constipation
- Growing problem of FBD (Functional Bowel disorders)
- Inefficacy and abuse of laxatives
- Potential benefits of colon irrigation
- Interest in the procedure remain prevalent
- Increasing number of clinical publications
Threat remains unless…
- The practice of colon hydrotherapy secures a level of medical credibility for itself
- More publication and presentation are available to explain the potentials of the procedure
- Better communication is established internally and externally to gain support and share resources
- Internal consensus to be developed to promote unity in thoughts and actions relating to all aspects of the practice of colon hydrotherapy
FBD-Constipation
- Report at Digestive Disease Week, L.A.
- Results of Global survey of constipation
- 13,879 participants from 4 continents
- 12% population worldwide suffers from it
- Asia-Pacific region and Americans highest incidence at mean of 17.3%
- Europe on 8.75%
- Asian lowest use of laxatives 2 in 10
- 40% resorted to lifestyle modification as Rx