1645 A Case of Proctocolitis Secondary to the Use of Coffee Enema

Abstract

INTRODUCTION: Proponents of coffee enemas advocate for its role in cancer treatment, where it is believed to detoxify via vasodilation and toxin excretion. However, there is no science-based evidence to verify these claims, and its use is associated with harmful effects, including electrolyte imbalances and death. We present a case of coffee-enema induced proctocolitis (PC). CASE DESCRIPTION/METHODS: A 40-year-old woman presented with acute abdominal pain, bloody diarrhea, and tenesmus. She denied recent travel or sick contacts. She had mixed-type IBS, but denied ever experiencing symptoms this severe. Her brother had ulcerative colitis (UC) and aunts had Crohn’s Disease. CT showed severe PC from rectum to descending colon. WBC 21.8, CRP 23, FLA was positive; however, C. Diff, shiga toxin, stool culture, lipase, LFTs were unremarkable. On day 2, she admitted to using 500mL of room temperature coffee enema to treat gallstones, hours prior to symptom onset, which “never came back out.” Flexible sigmoidoscopy displayed severe rectal inflammation, extending to 60cm depth. She was empirically started on Solu-Medrol. Biopsy revealed necrotic mucosa and purulent exudate, suggesting ischemic colitis (IC), but no crypt abscesses. Repeat sigmoidoscopy on day 10 showed improvement of damage, extending to 30cm depth. Clinical improvement was slow, and she was finally discharged on day 13. DISCUSSION: A few South Korean reports of coffee enema induced PC exist in literature. Our patient presented similarly to those cases, suggesting a consistent process through which it achieves its damage. PC occurs in UC, but our patient’s biopsy was more suggestive of IC. IC usually spares rectum due to rich blood supply; our patient’s rectum was not spared. Caffeine may decrease blood flow through a variety of mechanisms (e.g., blocking cGMP formation) and could lead to ischemia. Additionally, it blocks adenosine A2 receptors (AA2Rs). In animal models, AA2R activation attenuates intestinal inflammation, so inhibition may lead to inflammation. Our patient’s PC was likely due to direct contact injury, as well as damage from activation of inflammation and blood flow alteration. Our patient planned to follow up with her naturopathic doctor who recommended the enema. She blamed herself for using too much coffee and could not be persuaded that coffee enemas pose more risk than benefit. It is imperative we educate on risks of “natural” remedies and work to develop trusting relationships with patients so they accept evidence-based practice.