Hydrotherapy has been the butt of a lot of jokes.
Okay, thanks for letting me get that out of my system. So to speak.
We all know bowel prep is the critical factor in ensuring a successful colonoscopy. So much so, there’s a rating system for it: the Boston Bowel Preparation Scale (BPPS). (You have to wonder who drew the short straw to decide exactly how much fecal matter determined the “degree of soiling” level?) In the BPPS, the bowel is divided into three sections—right colon, transverse colon, and left colon—and then further segmented by degree of soiling. First published in 2009 by Edwin Lai and associates, the BPPS was part of a 2016 systematic review of colon-cleansing scales—including Ottawa Aronchick and Harefield, among others. Authors Robin Parmar and associates concluded that “The BBPS is the most thoroughly validated scale and should be used in a clinical setting.” The scale now is used and accepted worldwide.
But let’s face it: Scale or no scale, patients hate colonoscopy bowel prep. They just do. The uncomfortable, undignified process has become fodder for objectors and comedians alike. And who can blame them when side effects can include nausea, vomiting, bloating and, in some cases, increased hemorrhoidal flare and loss of sleep? But the success of a colonoscopy depends heavily on how well the patient follows prep instructions.
If the patient is indifferent, well—crap gets in the way of the exam. In a 2022 prospective observational study, Niels Teich and associates wrote, “Patients often consider [bowel prep] to be the most burdensome part of colonoscopy, which might be a main barrier to the procedure.” Some people simply refuse to schedule their colonoscopy—all because of what they’ve heard about the prep.
Hydrotherapy is a method of cleaning out the colon working from the bottom up, rather than the top down, by irrigating the colon with warm water. In some cases, massage is introduced to help loosen fecal matter. According to ColonicsDetox, based in the United Kingdom, the method has been in practice for thousands of years, with origins in Egypt, Greece and India. “It is an integral part of a modern naturopathic approach to health and was used in hospitals until the 1970s. The ultimate detox, it’s a very safe and gentle treatment,” the website states.
Teich, et al., wrote, “… bowel cleansing quality of colonic irrigation is considered comparable to oral purgative [regimens] but with less side effects and high patient satisfaction.” The study examined the efficacy of colonic irrigation as a method of bowel prep, using a new colon hydrotherapy device. They found the device to be “an effective and low-risk alternative to traditional oral preparation.”
Trouble in Paradise
The problem with bowel prep isn’t always with patient noncompliance. To put it indelicately, some patients are simply more full of crap. Some patients may have medical conditions that predispose them to problematic prep. And patients are always pressing for a more palatable regimen that includes lower volume.
Cristina Rutherford and Audrey Calderwood wrote in Current Treatment Options in Gastroenterology that between 10% and 25% of patients have “inadequate colon cleansing” on the day of their colonoscopy.
The big question is, why? Were patients noncompliant? Or was the prep inadequate? Practitioners can help facilitate answers to these questions, although this can be tricky: Will a patient hide the truth if she didn’t drink the whole prep? Or will she, like me, admit she had to stop about two-thirds of the way because she came close to vomiting and there was nothing coming out of her but bile, anyway? (Full disclosure: My gastroenterologist said my prep was fine and she had no trouble visualizing.) But I’m an average-sized woman of low weight. Should the same prep be used for me that’s prescribed for a 300-pound man who eats nothing but cheeseburgers?
Nabil Fayad and associates asked that same question in the journal Clinical Gastroenterology and Hepatology. In a 2013 retrospective study, they discovered that bowel prep was inadequate for 44.2% of patients who, it turned out, had “significantly higher mean BMIs” than those for whom prep was adequate. Their takeaway? “BMI is an independent factor associated with inadequate split bowel preparation for colonoscopy,” they wrote. But they also cited additional factors that might affect prep, including “diabetes, hypertension, dementia, and use of tobacco and narcotics. Patients with BMIs ≥ 30 kg/m2 should be considered for more intensive preparation regimens.”
Conversely, a 2019 observational study published in the Journal of Clinical Gastroenterology found no correlation between obesity and bowel prep; instead, the authors cited factors such as male gender, diabetes, liver cirrhosis, coronary artery disease, refractory constipation and current smoking as predictive of poor bowel preparation.
In a 2021 narrative review, Emanuele Sinagra and associates examined a low-volume polyethylene glycol/ascorbic acid solution (PEG-Asc) that might improve patient compliance. But they emphasized that a “one size fits all” prep is not feasible, and “a bowel preparation [regimen] must always be selected and tailored by the clinician for each patient, evaluating the best options on a case-by-case basis.”
Just Add Water
With hydrotherapy, poor prep is no longer a pressing problem. At GI Associates in Mississippi, patients are already enjoying the ease and benefits of hydrotherapy. The FDA-approved HygiPrep system allows the patient to be treated in a private room during the process. While seated in a sanitized basin, the patient inserts a sterile, disposable nozzle into the rectum, and a gentle stream of warm water is introduced, which loosens fecal matter and cleans the colon. Sanitary and odorless, the process takes less than an hour.
Possible side effects of the procedure can include cramping, dizziness, nausea and vomiting, as well as “clinically insignificant rectal abrasians,” according to the online brochure. Other practitioners cite bloating and perianal soreness, electrolyte imbalance, bowel perforation, liver toxicity, water intoxication, and infection. In an abstract published in the American Journal of Gastroenterology, Amulya Reddy and associates wrote, “It is thought that increased intraluminal pressure during colonic hydrotherapy results in bacterial translocation into the peritoneal cavity.” And the process isn’t for everyone: patients with congestive heart failure, renal insufficiency or intestinal perforation should not use HygiPrep.
That said, GI practitioners gave the process a 98% approval rating for cleanliness; nearly 2500 patients scored it even higher, with 99% saying the experience was “good” or “very good.”
One of the few controlled studies available on colonic hydrotherapy compared it with a polyethylene glycol electrolyte lavage (PEG-EL) solution. The findings were interesting: While the PEG-EL group had better colonic cleanliness, and fewer adverse effects, which went over well with practitioners, the hydrotherapy group boasted higher diverticulosis detection rates and higher patient satisfaction.
Community Feedback
While we might improve patient satisfaction by splitting the prep solution or going with hydrotherapy, one group that’s not happy with the whole “cleaning out the colon” thing is our microbiome.
The microbiome is a teeming collection of beneficial bacterial hordes that live quite happily in our gut. Without this tiny community, our gut could not function. These “good bugs” help digest our food, balance our immune system, and destroy bad bacteria that cause disease. Most of the beneficial stuff that happens in our small intestine, happens because of the good bacteria; they produce enzymes to break down indigestible carbohydrates, ferreting out the nutrients our body needs. And as you probably already suspect, what we eat has a big impact on our microbiome, with fruits, vegetables and whole grains getting a big thumbs up, but processed foods and those high in fat and sodium, not so much.
In Integrative Medicine: A Clinician’s Journal, Matthew Bull and Nigel Plummer wrote, “Imbalance of the normal gut microbiota have been linked with gastrointestinal conditions such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), and wider systemic manifestations of disease such as obesity, type 2 diabetes, and atopy.” So not only is it important to possess a microbiome—it’s also important to keep the little guys happy and functioning properly.
Amit Gajera and associates noted that patients with IBD must endure frequent colonoscopies because of their higher risk for colorectal cancer. However, the prep often becomes burdensome. “Additionally, oral BP has been noted to possibly induce colon mucosal inflammatory changes in some patients, which may be misleading when assessing actual disease activity,” they wrote. Mucosa visualization is critical to IBD diagnosis, so the disruption of gut mucosa caused by oral purgative-based preps, “especially those containing sodium phosphate,” can skew the exam’s results.
In addition, they argued that mucosa can suffer injury from oral preps, especially those that contain sodium phosphate, “even to the point that it mimics CD.” One of the benefits of HygiPrep is that it does not use mucosa-affecting chemicals. “The prep induced peristalsis as the water gently flows in the gut lumen and naturally loosens the colon content, including that of the ascending (right) colon,” they wrote. “Therefore, this prep is likely to be less disruptive for the bowels of IBD patients and circumvents the disruptive nature of the oral purgative prep while providing a more accurate assessment of disease activity.”
While many practitioners argue that a nice colon cleanse is good for us, our bacteria family—if they could—would claim otherwise.
In a randomized controlled trial, Jonna Jalanka and associates examined two study groups who consumed prep in a single dose or two separated doses. The team examined fecal samples taken for a baseline, after bowel cleansing, and at 14 days and 28 days post-treatment. What they found was that although the patients’ bacterial communities were restored by 14 days, “the rate of recovery was dose dependent: consumption of the purgative in a single dose had a more severe effect on the microbiota composition than that of a double dose, and notably increased the levels of Proteobacteria, Fusobacteria and bacteria related to Dorea formicigenerans. The abundance of the latter also correlated with the amount of faecal serine proteases that were increased after purging.” Cleansing by using two separated doses turned out to be easier on the gut’s microbiota.
No one’s arguing that we should give up colonoscopies. But it’s good for practitioners to be aware of the prep’s impact on our microbiota, especially for patients with IBS, Crohn’s or other conditions that may be negatively affected.
As Gajera and associates wrote, “Using this BP for IBD patients can allow earlier interventions, significantly impacting disease management and future outcomes.” If the procedure increases compliance among IBD patients, it could also do the same among the general population.
The only thing hydrotherapy won’t change is the late-night comedy jokes.
