Regularity über alles, revisited

File this under “Well, duh!”

In thinking about “alternative” medicine, occasionally I contemplate the deepest, most profound questions having to do with health and healing, the difference between science-based medicine and evidence-based medicine, and how to maximize the therapeutic effect of scientifically validated treatments. Other times, I contemplate the question of just what is, based on logic and basic science alone, the most ridiculous “alternative medicine” therapy of all time.

Certainly, there are many contenders. For example, there is homeopathy, which is basically nothing more than sympathetic magic in which water is claimed to retain the memory of whateve therapeutic substance the homepath wants to use but, at Tim Minchin puts it, to forget all the poo it’s been in contact with. Then there’s reiki, which, boiled down to its essence, is nothing more than faith healing, substituting a “universal energy” for the Christian god. Oh, and reiki isn’t “ancient,” either. It was invented in 1920. Then, of course, there are the ever-infamous Kinoki footpads or the “detox footbaths.” They’re both basically the same thing, wherein quacks claim that you can actually eliminate “toxins” through the soles of your feet. They’re also both equally scams, with only the mechanism of producing an apparently “positive” result differing. Either way, however, a credulous mark is separated from his greenbacks.

One form of alternative medicine quackery, however, that never fails to amaze me with its combination of utter nonsense and ridiculousness, coupled with the sheer disgustingness of it all, is, of course, colon cleansing. It’s something that I’ve written about periodically during the history of this blog (and even transplanted to my other blog), be it writing about how quacks falsely claim that “death begins in the colon,” that “dual action cleanse” does anything other than make you poop, or making fun of a form of colon cleansing so ludicrious that even the most credulous believer in alternative medicine can’t possibly believe it. Or maybe he could. Over the years, I’ve seen so much utter nonsense swallowed whole and regurgitated as though it were fact and science that I no longer believe there is any form of pseudoscience so nonsensical that someone, somewhere (and usually many people in many places) won’t believe it. I’m still waiting for butt reflexology to catch on, and, actually, in some places it did.

So, even though colon cleansing is one of the stupidest–yes, stupidest–forms of alternative medicine I’ve ever encountered, there is indeed a large contingent of credulous believers who also seem to have a fixation about cleanliness (not to mention their nether regions) who think that colon cleansing can “remove toxins in order to treat a wide variety of diseases and conditions. Let’s not forget, for instance, that the Gonzalez protocol for cancer is basically a radical diet, coupled with lots of supplements and lots of coffee enemas. There’s even a Guild of Colon Hydrotherapists, not to mention the International Association for Colon Hydrotherapy, both of which to me certainly strive for the title of most useless organization ever conceived, an organization that even goes so far as to claim that Jesus advocated colon cleansing. I suppose that latter claim is possible, given that colon cleansing dates back to ancient Egypt and is based on the idea that our colons can’t handle the waste and “toxins,” leading to all the poo in our colons leeching into our bloodstreams and poisoning us, a concept known as “autointoxication.”

Because I’ve written so much about just how silly a form of quackery colon cleansing is, when you, my readers, first started sending me links to this article, entitled Colon Detox Not Backed by Science, at first I resisted. After all, Orac is nothing if not a cantankerous box of multicolored blinking lights, and he hates being told what to do. On the other hand, he does, for all his alleged computer nature, feel a fierce loyalty to his readers, and, if his readers want him to blog about colon cleansing again and are deluging him with requests, well, then, damned if he won’t blog about colon cleansing again! Never let it be said of Orac that he doesn’t give his readers what they want (well, most of the time, anyway). Besides, this is actually an amazing little bit of victory for the forces of science-based medicine, as you will see. First, let’s take a look:

Colon cleansing has no evidence to support its use, and can lead to pain, vomiting, and fatal infections, according to a new report.

“A search of the literature using the terms ‘colon cleansing,’ ‘herbal colon cleanse,’ ‘colon detoxification,’ and ‘colon irrigation,’ yielded no scientifically robust studies in support of this practice,” wrote Ranit Mishori, MD, of Georgetown University in Washington, D.C., and colleagues, in the August Journal of Family Practice.

Colon cleansing has been practiced since antiquity as a means of enhancing health through ridding the body of toxins. These procedures are similar to enemas, except that volumes in excess of 60 liters sometimes are used, and the procedure may be done repeatedly.

60 liters? Those of you out there who’ve hit the age of 50 and had to undergo screening colonoscopy (or those of you who’ve needed a colonoscopy for a complaint such as rectal bleeding) have experienced the joy of drinking a mere 4 L of GoLytely, only to see it flow right through you and come out the other end. Imagine having fifteen times that volume being placed in your nether regions over time and squirting it out again. Gross? Well, of course it is. But that’s what we’re talking about here, and never let it be said, either, that Orac shies away from a topic just because it’s digusting. It never ceases to amaze me what people will subject themselves too when they think it is somehow beneficial.

So let’s take a look at the article itself. Interestingly, it was published by faculty at the Georgetown University School of Medicine. Those who’ve been longtime readers might recognize why I mention this. Yes, Georgetown is a school that is deeply entrenched in woo, so much so that it “pioneered” the “integration” of quackery in its mandatory medical curriculum. No more was it enough to offer various complementary and alternative medicine (CAM) rotations as electives for fourth year medical students. that wasn’t “integrative enough” so the powers that be at Georgetown “integrated” pseudoscience into their medical school curriculum. More recently (this year, in fact), Georgetown signed an agreement with that school of quackery naturopathy, Bastyr University, to help train the next generation of CAM practitioners. The only reason that I mention these things is that it’s a hopeful sign that faculty at Georgetown University are holding out against the tsunami of quackademic medicine that must be washing over them. And hold out they do, delivering a devastating critique (OK, debunking) of the quackery that is “colon hydrotherapy” or “colon cleansing.”

First off, not only does colon cleansing not provide the benefits claimed for it, but it is not a safe procedure. There are a number of complications that cna occur, ranging from the unpleasant to the genuinely life-threatening:

Most reports in the literature note a variety of adverse effects of colon cleansing that range from mild (eg, cramping, abdominal pain, fullness, bloating, nausea, vomiting, perianal irritation, and soreness) to severe (eg, electrolyte imbalance and renal failure). Some herbal preparations have also been associated with aplastic anemia and liver toxicity.

Case reports also have noted back and pelvic abscesses after colonic hydrotherapy, fatal aeroportia (gas accumulation in the mesenteric veins) with air emboli, rectal perforations, perineal gangrene, acute water intoxication, coffee enema-associated colitis and septicemia, and deaths due to amebiasis.

All of these are easily predictable by anyone who knows a bit about the anatomy and physiology of the colon (like a surgeon–like me). All medicine is a balancing of risks versus benefits. Unfortunately, in this case, the procedure is all risk, no benefit.

There is one curious bit in the article, though. Let’s see if you can see why I found this passage rather curious:

The preparations used for colon cleansing are considered dietary supplements, and the US Food and Drug Administration (FDA) requires that they be labeled as such; the FDA does not preapprove these substances, however. The FDA also requires that colonic hydrotherapy and irrigation system devices meet certain requirements, but the agency has never approved any system for general nonmedical purposes, such as colon cleansing.

Apparently the FDA has a different definition of “dietary supplement” than most people would have. Personally, I consider dietary supplements to be something that one ingests in the correct end of the gastrointestinal tract, not something that one shoots up the hole where things usually exit. Yes, I know what the authors are getting at, but, really, does it matter that much whether what’s put in the hydrotherapy fluid is considered a dietary supplement under FDA regulations and the DSHEA of 1994? I think not. On the other hand, what I can’t figure out is how colon cleansers get away with coming up with all these cobbled-together devices to deliver the goods, so to speak. After all, these devices have an FDA Class III designation. That means that if a device is used for purposes beyond what is medically indicated, such as preparation for radiologic and endoscopic procedures, then the manufacturer must obtain premarket approval from the FDA. Guess how many of these manufacturers bother to get such approval?

The authors conclude with four things they recommend telling patients about colon cleansing. Personally, I think that only two things are necessary. First, ask them what the hell they’re thinking and, second, point out that the colon rarely needs assistance in doing its job. OK, OK, I know. As a physician, I can’t be judgmental, and, believe me, when interacting with actual patients I do my damnedest not to be. On the other hand, if you’re not a physician or other health care professional, you’re under no such obligation. Be that as it may, in lieu of these points, then I suppose you can tell patients the more conservative things that the authors recommend:

  1. Colon irrigation is not wise–particularly if you have a history of gastrointestinal disease (including diverticulitis, Crohn’s disease, or ulcerative colitis) or a history of colon surgery, severe hemorrhoids, kidney disease, or heart disease. These conditions increase the risk of adverse effects.
  2. Side effects of colon cleansing include nausea, vomiting, diarrhea, dizziness, dehydration, electrolyte abnormalities, acute kidney insufficiency, pancreatitis, bowel perforation, heart failure, and infection.
  3. The devices that practitioners use for the procedure are not approved for colon cleansing by the US Food and Drug Administration. Inadequately disinfected or sterilized irrigation machines have been linked to bacterial contamination.
  4. Colon cleansing practitioners are not licensed by a scientifically based organization. Rather, practitioners have undergone a training process structured by an organization that is attempting to institute its own certification and licensing requirements.

All of this is good, solid, boring advice. My further advice, though, when it comes to colon cleansing would be to quote a former First Lady, who, whether you liked her or not, did come up with a most excellently pithy catchphrase that, while being an utter failure when it comes to drugs, might function quite well with respect to colon cleansing: Just say no. Your colon will thank you.