A Case of Coffee Enema Induced Rectal Burn, Proctocolitis, Sub-Acute Intestinal Obstruction, and Electrolyte Imbalance: A Case Report ()
1. Introduction
Coffee enemas are part of complementary and alternative medicine (CAM). Though it is claimed that coffee enemas have beneficial effects on detoxification and cancer treatment, systematic reviews demonstrate no proven therapeutic benefit and instead highlight risks including infection, burn, perforation and electrolyte imbalance [1]. Coffee enemas maybe dangerous when self-administered with boiling temperature or excessively hot preparations, increasing the risk of mucosal burn and perforation [2]. Here we report a case of severe rectal burn and proctocolitis resulting in a fibrotic stricture and subacute intestinal obstruction caused by a single, self-administered hot coffee enema.
2. Case Presentation
Figure 1. Sigmoidoscopy: Sigmoid colon up to 20 cm from the anal verge shows mucosal erythema, erosions, ulceration, and narrowing of the lumen. The scope could not be passed beyond. Mucosa and vascular pattern of the rectum are normal.
Figure 2. Plain X-ray abdomen: Distended bowel loops with obstruction.
Figure 3. Repeat Sigmoidoscopy: Revealed similar findings of mucosal erythema, erosions, ulceration, and luminal narrowing.
Figure 4. Histopathological section showing colonic mucosa and ulcerated fragments with fibrinopurulent exudate. The ulcerated fragments comprise granulation tissue infiltrated by acute and chronic inflammatory cells. The colonic mucosa shows unremarkable crypt architecture with mild chronic inflammatory-cell infiltration in the lamina propria (H&E stain, ×40 magnification).
Figure 5. CT Scan abdomen: Diffuse wall thickening at the sigmoid and descending colon (arrow).
A 30-year-old obese man, recently diagnosed with T2 diabetes mellitus, underwent a self-administered coffee enema using hot boiling water to control his diabetes. At first he mixed 3 tablespoons full of organic, ground coffee in one liter of filtered water and boiled it for 5 minutes. Then without cooling down to body temperature and without filtering coffee he took it in an enema bag and self introduced this hot coffee enema through a soft nozzle. He felt intense lower abdominal and anal pain and evacuated the enema immediately. Then he was admitted to a tertiary care hospital through the emergency department and was subsequently transferred to the ICU because of subacute intestinal obstruction, sepsis, acute kidney injury, and hemodynamic instability. Initial sigmoidoscopy showed mucosal erythema, erosions, ulceration, and luminal narrowing; the scope could not be advanced beyond 20 cm from the anal verge (Figure 1). Routine stool examination was normal and stool culture reviewed no growth. His fecal calprotectin level was near normal (66). After 15 days, he was discharged with partial clinical improvement. Forty-five days later, he was readmitted with persistent lower abdominal pain, poor oral intake, approximately 10 kg weight loss, and persistent diarrhea (8 - 10 times/day), occasionally with blood. He developed severe anemia (hemoglobin 6%), sever hyponatremia and hypokalemia (Na-119, K-1.9), and subacute intestinal obstruction (Figure 2). He was kept nothing by mouth and managed with intravenous fluid and electrolyte replacement, blood transfusion, broad-spectrum antibiotics, sucralfate, and corticosteroid (Hydrocortisone) enema. After clinical improvement, repeat sigmoidoscopy revealed similar findings of mucosal erythema, erosions, ulceration, and luminal narrowing (Figure 3). Histopathological examination showed unremarkable crypt architecture with infiltration of acute and chronic inflammatory cells in the lamina propria (Figure 4). CT scan of abdomen showed diffuse wall thickening in sigmoid colon and descending colon with proximal dilatation (Figure 5).
Based on the clinical, endoscopic, histopathological, and radiological findings, the patient was diagnosed as coffee enema-induced rectal burn, proctocolitis, fibrotic stricture and subacute intestinal obstruction. Surgical consultation was taken and partial colectomy was advised.
3. Discussion
Coffee is one of the most popularly consumed beverage through out the world. Epidemiological studies have suggested that coffee consumption may reduce the risk of cardiovascular disease, metabolic disorders such as diabetes mellitus, neurodegenerative diseases including Parkinson’s disease and Alzheimer’s disease, and overall mortality. Beneficial effects have also been reported in several malignancies, including hepatocellular and colorectal cancers.
Enemas have been used for thousands of years in different civilizations. Historically, enemas are used for bowel cleansing, nutritional support, drug delivery and religious rituals.
Coffee enemas became popular when Dr. Max Gerson incorporated them into Gerson Therapy during the 1930s for the treatment of chronic degenerative diseases, including cancer, diabetes, and tuberculosis [3]-[6]. It is claimed that coffee constituents such as kahweol and cafestol stimulate glutathione S-transferase activity, thus enhance hepatic detoxification and elimination of carcinogens. However, studies have not shown significant increase in serum glutathione level after coffee enemas [7]. In addition, caffeine absorption is much lower when coffee is given through the rectum than when it is taken by mouth [8]. In general, there is no strong evidence that coffee enemas provide therapeutic benefits.
There is minimal clinical evidence that coffee enemas are effective. One Korean study showed that coffee enemas improved constipation [9]. Nevertheless, these findings have not been confirmed by well-designed clinical studies. In contrast, a randomized clinical trial showed significant longer survival among patients with pancreatic cancer treated with gemcitabine-based chemotherapy compared with pancreatic enzyme therapy combined with alternative treatments, including coffee enemas [10].
A systematic review depicted several case reports showing complications caused by self-administered coffee enemas [1]. Serious side effects have been reported. Fatal complications have included severe electrolyte disturbances [11] and polymicrobial enteric septicemia [12]. Serious colorectal injuries have also been reported, including rectal burns, rectal perforation, colitis, and proctocolitis [2] [13]-[18].
The present case is remarkable because a single self-administered hot coffee enema resulted in severe rectal burn with subsequent proctocolitis, progressive fibrosis, rectal stricture, and recurrent subacute intestinal obstruction requiring definitive surgical management. Compared with previously reported cases, our patient developed a delayed fibrotic complication that ultimately necessitated operative intervention, highlighting the potential for irreversible long-term morbidity.
In conclusion, coffee enemas should not be considered harmless complementary therapies. Despite continued promotion through the internet and complementary and alternative medicine practitioners as natural detoxifier, there current evidence does not support their therapeutic efficacy. Instead it may cause the potential for severe, irreversible, and even fatal complications. Healthcare professionals should counsel patients regarding these risks and discourage the use of coffee enemas specially when it used unsupervised.
4. Conclusion
The effectiveness of coffee enemas as a therapeutic measure is unsubstantiated and lacks empirical validation. This case demonstrates that self-administration can lead to severe thermal and chemical injury, resulting in debilitating complications such as proctocolitis, life-threatening electrolyte imbalances, and chronic fibrotic strictures requiring surgical correction. As coffee enemas can cause serious harm, their use should be discouraged. In spite of extensive promotion, there is no strong scientific evidence that coffee enemas are beneficial. Clinicians should counsel patients against unregulated CAM practices and recommend for evidence-based treatments. Further research is needed to address the gap for better understanding and prevention of coffee enema related complications.