Chronic Granulomatous Colitis Following Coffee Enema

Abstract

Purpose: A 59-year-old previously healthy female presented with lower abdominal pain, rectal urgency, and hematochezia 36 hours after instillation of a room-temperature coffee enema. Her physical exam was pertinent for tenderness in the right lower quadrant. Admission laboratory data showed leukocytosis, and computed tomography demonstrated rectosigmoid colon thickening. Flexible sigmoidoscopy demonstrated severe colitis and narrowing within eight cm of the anal verge. Histologic findings revealed severe nonspecific colitis. Symptoms of lower abdominal pain with up to 10 small caliber, bloody stools per day persisted. Within months, she developed several strictures in association with persistent colitis in the rectosigmoid colon, eventually requiring resection of 30 cm of rectosigmoid colon 6 months after the enema exposure. Surgical pathology specimen revealed foreign body-type giant cell granulomata with inflammation through the muscularis layer to the serosa. Stains for infectious organisms were negative. Endoscopic and histologic examination of the remainder of the colon and terminal ileum four months after surgical resection revealed no evidence of idiopathic inflammatory bowel disease above severe foreign body granulomatous proctitis and stricture. This is the first report of coffee enema leading to chronic foreign body granulomatous colitis. To date, there have been nine reported cases of complications related to coffee enema use. However, the majority of these were thermal in nature. Similar to our case, one previous report suggested chemical etiology involving a cooled enema presenting days after exposure. Our case is unique in the chronicity of active inflammation, as well as the presence of foreign body granulomata. Coffee enemas have been gaining in popularity, most commonly cited for constipation relief and as a method of “detoxification.” This case highlights the potential harm associated with this unproven therapy. Animal models may help better understand what component of coffee may be responsible for inducing a chronic foreign body granulomatous transmural colitis.Figure: Chronic granulomatous colitis post pneumatic balloon dilation.