Proctocolitis Caused by Coffee Enemas - Nature

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of proctocolitis caused by coffee enema in Korea. We suggest that coffee enema carries considerable risk of provoking unwanted complications and should be.
Letters to the Editor

Proctocolitis Caused by Coffee Enemas Bora Keum, MD, PhD1, Yoon Tae Jeen, MD, PhD1, Sung Chul Park, MD1, Yeon Seok Seo, MD, PhD1, Yong Sik Kim, MD, PhD1, Hoon Jai Chun, MD, PhD1, Soon Ho Um, MD, PhD1, Chang Duck Kim, MD, PhD1 and Ho Sang Ryu, MD, PhD1

Figure 1. Initial colonoscopic findings. (a) Multiple geographic ulcers with exudates in the sigmoid colon. (b) Ulcers with regenerative epithelium in the rectum.

doi:10.1038/ajg.2009.505

To the Editor: Coffee enema has been used as an alternative therapy for various diseases, including cancer and constipation (1). However, its effect has not been proven and complications are not well known. Herein, we experienced a case of proctocolitis caused by coffee enema in Korea. We suggest that coffee enema carries considerable risk of provoking unwanted complications and should be reconsidered as an alternative treatment. A 60-year-old woman was admitted with hematochezia and severe anal pain. She had had a coffee enema 4 days earlier to relieve chronic constipation. The coffee enema fluid was prepared from two tablespoons of roasted ground coffee without additives and 1 liter of water, and cooled thereafter. After rectal infusion, she retained the fluid for 10 min and then evacuated the substance. Lower abdominal pain developed several hours later. The next day, she began to suffer from hematochezia, tenesmus, and spastic anal pain, with low abdominal pain worsening with time. On physical examination, tenderness was observed in the lower abdomen. Laboratory studies revealed the following: white blood cell (11,800 per mm3), hemoglobin (13.4 g/dl), and C-reactive protein (18.3 mg/dl). Other findings, including electrolytes, were not remarkable. On colonoscopy, multiple large geographic ulcers with exudates and regenerating epithelia in the sigmoid colon and rectum were observed (Figure 1). Histopathological evaluation showed features of acute inflammation, including mucosal erosion and infiltration of neutrophils without granuloma or crypt abscess. The patient recovered with antibiotics, intravenous fluid therapy, and bowel rest. One week later, a © 2010 by the American College of Gastroenterology

Figure 2. Follow-up colonoscopy after 3 months. (a) Stenosis at the rectosigmoid junction. (b) Complete healing ulcer with scar formation in the rectum.

follow-up sigmoidoscopy showed healing stage ulcers. On the ninth day after hospitalization, the patient’s condition improved enough to have a regular meal. At 3-month follow-up, the patient was asymptomatic, with colonoscopy showing ulcer scars on the sigmoid colon and rectum, with moderate stenosis at the rectosigmoid junction (Figure 2). Proponents of coffee enema claim that cafestol palmitate in coffee promotes glutathione S-transferase, which detoxifies the products of tumor cell metabolism, and that the enema fluid stimulates peristalsis and drainage of toxic bile from the gut. Although none of these hypotheses are proven, coffee enema has been used as an alternative therapy for various diseases, including cancer and constipation (1). Complications associated with coffee enema have rarely been reported. There were two cases of death related to coffee enemas that were associated with electrolyte imbalance caused by frequent enemas (2). In addition, one case of polymicrobial enteric septicemia from coffee enema in an advanced breast cancer patient was reported (3). However, there have been no reports on colonic inflammation caused by coffee enema. Recently, a case of rectal burn associated with hotwater coffee enema was reported, but it

seems to have been caused by hot water and not by the coffee itself. In our case, the coffee enema fluid was prepared from two tablespoons of roasted ground coffee without additives and 1 liter of water, and the solution was cooled. Thus, the complication can be attributed not to thermal injury but to certain chemicals in coffee. Coffee is a complex mixture of chemicals that contains chlorogenic acid, caffeine, cafestol, and kahweol, which may cause adverse effects. Although the mechanism on coffee enema-induced proctocolitis is not known, the possibility of chemical colitis should be considered. In Korea, two more cases of acute proctocolitis related to coffee enema have been reported (4,5). All three cases, including ours, demonstrated a similar enema procedure and clinical course. The time interval from carrying out coffee enema to the appearance of the first symptom, as well as endoscopic findings and outcomes, in all three cases was similar. Proctocolitis was not dependent on the concentration of coffee fluid and retention time. Furthermore, a single enema procedure was enough to cause proctocolitis in all three patients. Coffee enema has no proven benefit and carries considerable risk of provoking unwanted complications. Currently, we do not know which chemicals in coffee are The American Journal of GASTROENTEROLOGY

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Letters to the Editor

responsible and what the mechanisms are, but it is certain that coffee enema should be reconsidered as an alternative treatment. CONFLICT OF INTEREST

The authors declare no conflict of interest. REFERENCES 1. Green S. A critique of the rationale for cancer treatment with coffee enemas and diet. JAMA 1992;268:3224–7. 2. Eisele JW, Reay DT. Deaths related to coffee enemas. JAMA 1980;244:1608–9. 3. Margolin KA, Green MR. Polymicrobial enteric septicemia from coffee enemas. West J Med 1984;140:460. 4. Lee CJ, Song SK, Jeon JH et al. Coffee enema induced acute colitis. Korean J Gastroenterol 2008;52:251–4. 5. Choi JW JYJ, Kim S C, Myung S J et al. A case of coffee enema-induced colitis. Korean J Gastrointest Endosc 2005;31:427–31. 1 Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea. Correspondence: Yoon Tae Jeen, MD, PhD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Anam Hospital, Institute of Digestive Disease and Nutrition, Korea University College of Medicine, 126-1 5-ga, Anam-dong, Seongbuk-gu, Seoul 136-705, Korea. E-mail: [email protected]

Recanalization of Obstructed Choledochojejunostomy Using the Magnet Compression Anastomosis Technique Koichi Suyama, MD, PhD1, Hiroshi Takamori, MD, PhD1, Eigoro Yamanouchi, MD, PhD3, Hiroshi Tanaka, MD1, Yasuo Sakamoto, MD, PhD1, Yoshiaki Ikuta, MD, PhD1, Yoko Maki, MD2, Koichi Sakurai, MD, PhD2, Masahiko Hirota, MD, PhD1 and Hideo Baba, MD, PhD, FACS1 doi:10.1038/ajg.2009.473

To the Editor: A 78-year-old man had undergone en bloc resection of his gallbladder and extrahepatic bile duct, with dissection of the regional lymph nodes for gallbladder cancer. Biliary reconstruction was performed by cholangiojejunostomy in Roux-en-Y style. He was admitted to our hospital with obstructive The American Journal of GASTROENTEROLOGY

Figure 1. Percutaneous transhepatic cholangiography showing complete biliary obstruction of the choledochojejunostomy (arrow).

a

a Enteroscope

Enteroscope

Obstruction

Obstruction

b

PTBD tube

PTBD tube b

Guidewire

Figure 2. A magnet compression anastomosis procedure. (a) The daughter magnet attached to the guidewire tip (a) was inserted through the percutaneous transhepatic biliary drainage fistula. A parent magnet (b) was inserted into the jejunal limb of the choledochojejunostomy using a double-balloon endoscope. (b) The two magnets were bound to each other and they compressed the obstruction site from both sides.

jaundice 1 year after curative operation. Abdominal ultrasonography showed the dilated intrahepatic bile duct. Percutaneous transhepatic cholangiography disclosed the complete obstruction of cholangiojejunostomy (Figure 1). We tried four times to recanalize the obstruction via the percutaneous transhepatic biliary drainage (PTBD) route but were unsuccessful. Thereafter, we applied the magnet compression anastomosis (MCA) technique. To create an insertion route for the daughter magnet (diameter 4 mm; Magna, Tokyo, Japan) into the hepatic side, the PTBD fistula was gradually dilated from 8 to 18 Fr. The daughter magnet, attached to the tip of a guidewire, was inserted into the hepatic side of the obstruction through the PTBD fistula (Figure 2a). The parent magnet (diameter 5 mm; Magna) was inserted into the jejunal limb using a double-balloon endoscope (working 1 channel, FUJIFILM Medical, Tokyo,

Japan) and a guidewire (CREATE MEDIC, Yokohama, Japan). First, we carefully inserted the endoscope into the obstructed anastomosis by using the double-balloon technique, and left the guidewire close to the anastomosis using an endoscopic channel. Then, we removed the endoscope and advanced the parent magnet over the guidewire by using the endoscope (Figure 2a). The two magnets immediately bound to each other after approximation and began to compress the obstructed site (Figure 2b) (1). Reanastomosis was established 34 days after starting the compression. The internal stent tube was indwelled via the PTBD route for 6 months to maintain the patency of the anastomosis. Yamanouchi et al. (2) developed MCA by using two samarium–cobalt rare-earth magnets to create non-surgical, sutureless enteric anastomosis with the interventional radiological technique. The clinical feasibility, safety, and usefulness of VOLUME 105 | JANUARY 2010 www.amjgastro.com