Irrigation, lavage, colonic hydrotherapy: from beauty center to clinic?


E D I T O R I A L

Irrigation, lavage, colonic hydrotherapy: from beauty center
to clinic?

G. Bazzocchi1 • R. Giuberti2

Received: 4 November 2016 / Accepted: 20 November 2016 / Published online: 16 January 2017

� Springer International Publishing AG 2017

It is well known that in antiquity medicine often resorted to

the use of enemas and rectoclysis to ‘‘free’’ the body of the

‘‘humors’’ and ‘‘poisons’’ believed to originate in the

intestine and to cause diseases in many other organs.

Indeed, an Egyptian papyrus dating back to the XVI cen-

tury B.C. provides evidence of the belief that toxic sub-

stances produced by poorly digested foods could pass

through the intestinal lumen and into the blood stream

causing disorders even in distant organs. In the early 1900s

a British surgeon, Sir William Arbuthnot Lane, was pro-

foundly convinced of this theory: when the contents of the

large intestine stagnate, ‘‘toxic substances’’ are more easily

absorbed and lead to chronic disorders. As a result, he

performed extensive colectomies on patients with a wide

range of disorders: from arthritis to hypertension and skin

pathologies. In those same years, the British Medical

Journal published an article that concluded by saying that

fecal stasis altered colon bacterial flora, thus favoring

bacteria capable of toxin production (either anaerobes or

coliforms) with systemic effects [1].

The concept of ‘‘autointoxication’’ as a cause of disease

was later abandoned as modern medical research gained

sway and did not produce proof supporting this theory;

indeed, this topic incited heated debate in scientific circles.

In 1997, ‘‘Colonic irrigation and the theory of autointoxi-

cation’’ was defined as ‘‘a triumph of ignorance over sci-

ence’’ and those practicing it were deemed charlatans

holding false and obsolete beliefs that masked economic

interests [2].

Despite harsh criticism from the scientific community,

the practice of colonic lavage has remained deeply rooted

and the use of various instruments—from simple recto-

clysis that operates by force of gravity to complex (and

costly) colon hydrotherapy machinery—has continued to

be widely accepted. Going even further, we can say that

many patients request, and seek, this procedure and it is

practiced by scores of doctors. Today, the slogan ‘‘clean

on the inside—beautiful on the outside’’ has gained

widespread support from, for instance, the world of

fashion, the international jet set and the world of business.

Centers have sprung up offering colon lavage both for

esthetic reasons (it makes the skin lovelier!) and to

achieve a general feeling of wellness, on a par with a wide

selection of massages, baths, saunas and spa treatments.

In the city of Milan alone, there are approximately

2000–3000 people who undergo colon hydrotherapy ses-

sions at least once a month. This procedure is requested

by people who believe it is good per se, but also by a large

number of patients whose symptoms are associated with

one or more bowel disorders, according to the Rome III

Diagnostic Criteria that gastroenterology set up to orga-

nize itself at an international level, at least in terms of

nosology and diagnostic behavior, in the mare magnum of

symptoms that do not follow any precise and clear

anatomical and pathological pattern.

The phenomenon is so widespread that the undeniable

satisfaction perceived by those undergoing ‘‘intestinal

lavage’’ must be taken into consideration: in other words, it

cannot be simply the fruit of a campaign of misinformation

supported by speculative interests and word-of-mouth

indications based on ignorance. If nothing else, in view of

this consideration, we must take a careful look at the idea

& G. Bazzocchi
bazzocchi@montecatone.com

1
Neurogastroenterology and Intestinal Rehabilitation,

Montecatone Rehabilitation Institute, University of Bologna,

Bologna, Italy

2
SICT Società Idrocolonterapia, Milano, Italy

123

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that it is a useless, or even counterproductive, harmful

procedure.

Moreover, some controlled studies have appeared

comparing the effect of irrigation and lavage with con-

ventional treatment approaches, in particular, for consti-

pation and fecal incontinence which reap the greatest

benefits both in terms of symptoms and quality of life

[3–5]. These studies have used different irrigation methods

and do not reflect an ‘‘impeccable’’ experimental design.

However, beyond a shadow of a doubt, they do provide

enough data to assert, as a recent Dutch study has done,

that colonic irrigation is an effective treatment for

untreatable defecation disorders [6] and for patients with

functional disorders, as another paper concludes [7].

Moreover, some observations appear to indicate that

mechanisms reminiscent of ‘‘autointoxication’’ may come

into play. In one study of 57 patients with severe consti-

pation, an immune activation condition was reflected by

numerous indicators including elevated counts of CD3,

CD4 and CD25, increased spontaneous proliferation of

lymphocytes and increased ovoalbumin. Such activation

tended to normalize when constipation was relieved with

laxatives. The authors concluded that constipation is

associated with striking changes in fecal flora, intestinal

permeability and systemic immune response [8].

At the basis of the septic state so often found in inten-

sive care patients, from the first step of SIRS systemic

inflammatory response syndrome (SIRS) to the last step

resulting in inexorable multiple organ failure (MOF), it

appears that there is an overwhelming imbalance in the

intestinal flora and the translocation of some strains

through the mucosa with altered permeability [9]. A very

recent paper confirms that intestinal dysbiosis is a common

event in patients in intensive care units, and that it plays a

role in septic complications [10]. Coprostasis, bacterial

overgrowth, altered intestinal permeability, translocation

and absorption of substances derived from inefficient

digestive processes or from the metabolism of the altered

flora themselves all come together to create a scenario

which is now supported by a range of scientific evidence

[11, 12].

One strong argument against intestinal lavage has

always been the fact that the way this procedure works runs

exactly counter to such proven treatments as the adminis-

tration of dietary fiber and/or prebiotics and probiotics. On

the one hand, the colon is ‘‘emptied’’ out while, on the

other, the diet is supplemented with preparations that have

a bulking effect which, in turn, stimulate the ‘‘production’’

of adequate colon contents, thus increasing fecal volume.

We demonstrated that frequent, regular use of a steady-

pressure transanal irrigation procedure significantly

improves constipation, incontinence scores and the QoL in

a group of patients with ‘‘neurogenic bowel’’ resulting from

spinal cord injury [13]. These patients have been using this

technique for a few years now, some every other day and

some every 3 days maximum. We constantly verify that

their fecal output is normal in terms of both volume and

consistency. This is in direct contrast with the conviction

that lavage interferes with the development processes of

normal intestinal microbiota, which is well known to be the

main component of feces, making it difficult to maintain a

suitable intraluminal environment for formation and

transport of contents and thus forcing the patient to

increasingly resort to the procedure. On the contrary, it is

not unusual to find that, even after a single colon

hydrotherapy session, the patient starts to improve,

achieving evacuation that is satisfactory both in terms of

frequency and completeness. This may be because, fol-

lowing treatment, the patient appears to better handle the

administration of fiber, symbiotics and/or macrogol prod-

ucts which previously had caused abdominal discomfort

and were thus taken only sporadically.

We can, however, speculate that this gradual, light

methodical lavage, which can be extended for hours and

repeated, can actually ‘‘free up’’ the large intestine,

releasing fecal residues that were present for some time,

stuck to the intestinal walls, obstructing transport, causing

irritation and colon dysfunction. In summary, the regular

use of colon cleaning techniques could, in individuals with

serious intestinal motility problems, be an effective part of

the stability of intestinal microbiota. Recent observations

definitely support this idea that water use does not create

imbalances, but rather improves dysbiosis [14].

Mechanical distension of the colon walls is the ideal

mechanism for inducing high amplitude propagating

contractions, the only colonic motor pattern able to ensure

effective aboral transport of the endoluminal contents

[15, 16]. Modern transanal irrigation techniques also

make it possible to bring adequate volumes of water to the

more proximal colonic tracts, distending those sections.

Hence, the subsequent evacuation is not simply the result

of the action of the water per se, but also of induced

propulsive motility. It is evident that the content of the

ascending colon is also evacuated: post-irrigation studies

with radiopaque markers have shown this to be true

(Fig. 1) [17, 18].

In conclusion, there is adequate evidence based on

convincing clinical data to re-examine the scientific com-

munity’s total rejection of this method: rigorous studies

must be performed on their short- and long-term effec-

tiveness and also on the mechanisms of action involved in

those pathologies that improve significantly thanks to

lavage as a recent meta-analysis concludes [19].

Once again we may find that scientific evolution runs

counter to prejudices and to final ‘‘judgements’’ with no

right of appeal (Fig. 1).

2 Tech Coloproctol (2017) 21:1–4

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A sequence of abdominal X-ray films is showing what

happens in the colon of a patient with spinal cord injury

during a session of transanal irrigation (TAI) using a device

with a continent rectal catheter. After a radiopaque liquid

(gastrografin) has been diluted in the water, irrigation is

performed at the conclusion of an intestinal transit study

with radiopaque markers. After 7 days, most markers are

still retained along the entire large bowel. TAI starts after

catheter balloon inflation: after only 1 min, water has

climbed into the descending colon. Interestingly, markers

(and of course stools, where they are plunged) are pushed

up, into the splenic flexure. After 2 min from the beginning

of TAI, with the infusion of 450 ml of water, the hepatic

flexure is reached. When removing the probe, defecation

occurs with expulsion of water and contents from the

transverse colon and from the left colon. At the end,

radiopaque markers which are present in the right colon are

located in the sigmoid, and all the others are evacuated.

Compliance with ethical standards

Conflict of interest Gabriele Bazzocchi has served as an external
consultant and advisory board member for Coloplast and has served

as an advisory board member for Wellspect Health Care.

Ethical approval This article does not contain any studies with
human participants or animals performed by any of the authors.

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	Irrigation, lavage, colonic hydrotherapy: from beauty center to clinic?
	References