How long after an enema will I have a bowel movement?

Enemas for Constipation Relief

Some common steps in administering an enema include:

  • Drink one or two glasses of water prior to the enema, as it can cause you to become dehydrated.
  • Lie on your stomach with your knees pulled under you.
  • Lubricate the enema tube and gently insert it into your rectum.
  • If you’re using a disposable enema, gently squeeze the contents into your rectum. If you’re using an enema bag with a homemade solution, hold the bag up and allow gravity to deliver the contents.
  • Once the bag is empty, remove the tube from your rectum.
  • Wait in that position until you feel the need to move your bowels. You should feel a powerful urge within 2 to 10 minutes. Try to hold the enema in for at least 5 minutes to achieve maximum benefit.

Health Concerns Regarding Enemas

Because enemas can cause dehydration, overuse of enemas can create serious health problems. Use of enemas for constipation on a regular basis can lead to an electrolyte imbalance in the body called hyponatremia, in which the blood becomes diluted and its salt content becomes lower than normal. Hyponatremia can cause muscle spasms and swelling of the brain that leads to mental impairment. This is a particular concern when using enemas with plain tap water.

On the other extreme, overuse of phosphate enemas for constipation can lead to a condition called hyperphosphatemia, in which the blood levels of phosphate salts become elevated.

Be sure to consult with your doctor before using an enema, and exhaust all other possibilities first.

Learn more in the Everyday Health Digestive Health Center.

Constipation, as defined succinctly by Urban Dictionary, is when you’ve gotta go, but your ass says “no!” It is a diagnosis that I can truly empathize with – who hasn’t been at least a bit bunged up before?

The constipated patients that present to the ED take this everyday ailment to a whole new level. No one shows up a little constipated. Those that know they’re constipated come in as a last resort after trying the homemade remedies they saw on Dr. Oz. Those that don’t are diagnosed through a combination of clinical acumen, exclusion and a FOS x-ray. Regardless, it’s no fun to deal with for the nurses, the doctor or (most importantly) the patient. Regardless, they’re sick and tired of it and they want YOU to fix it. Help them Obi-Wan Kenobi, you’re their only hope.

While I have diagnosed and treated constipation, I didn’t have a great understanding of the treatment options or have a good Cocktail of my own. I suspect this is because:

-As a resident on the ward, I don’t actually take care of constipation. On the wards the nurses are monitoring the patient’s bowels and noting what treatments have been tried and worked (or didn’t).
-In the ER, I don’t know if my remedies worked or not unless there were instant results because my follow-up of constipation cases is nonexistent.
-Constipation cocktails seem to be as numerous as the bartenders that mix them with many doctors having their own “special recipe” and different services (ie gen surg vs peds vs obstetrics vs internal medicine) having different approaches at my institution. This has given me some experience with many treatments but minimal experience with any specific one.
-Poop, like me, doesn’t make it onto EMCrit. Scatology just ain’t that cool.

To make up for my ignorance, I have developed coping/survival strategies such as ordering whatever the nurses on the ward ask for (at least that way if it doesn’t work it’s not blamed on me) and, when in the ED, picking something the patient hasn’t already tried and sending them home to deal with their situation in precious privacy. I really wish I could just order up some lactu-seno-pico-glycol and let ‘er buck, but because I can’t it’s time to learn about it: BoringEM Style. My goal for this post is to delve into a Constipation Cocktail in sufficient depth to adopt it for my own practice (and maybe yours?).

Rather than coming up with my own untested Cocktail, I have adopted one that I was introduced to through #FOAMed on ERCast’s Constipation Manifesto podcast. Thanks to Rob Orman for his excellent podcast and Dr. Aaron Wall for sharing his recipe.

Dr. Wall’s Constipation Cocktail (aka the Orange Poly-Fleet – sounds yummy):

-Perform manual disempaction if indicated by stool in the rectal vault (the podcast has a great overview of an approach for this procedure)
-Provide 1/2 bottle (8oz or ~250mL) of Magnesium Citrate orally in the ED
-Advise the patient to mix 3-4 17g doses of Polyethylene Glycol daily until a soft stool is produced and then mix 1 17gdose daily for 3-4 weeks
-Recommend 1-2 Fleet Enemas daily for the next 2 days
-Counsel the patient to stop/limit the use of offending agents and to maintain well hydrated with oral fluids

So how do these drugs work? What are their contraindications? Complications? What should I tell the patient to expect? How much will they cost?

A Constipation Cocktail

Manual Disempaction
These are available free to all Canadians through sponsorship by our government (although you might have to wait in the queue for a bit). See the ERCast podcast for an excellent overview of how to perform this procedure. I’ve done it as many times as ZDogg.

Magnesium Citrate
It’s a generic, OTC osmotic laxative aka Citromag that is made up of magnesium and citric acid. As the magnesium salt is poorly absorbed in the intestine, fluid is retained in the bowels. This fluid should soften the stool by increasing its water content and also increase the intraluminal pressure to help push things along. Notably, it should be given on an empty stomach with water. Because it contains magnesium, hypermagnesemia (hypotension/resp depression) is a possible complication and it should be used cautiously in patients with poor renal function. As an osmotic diuretic, other electrolyte abnormalities could develop and are more likely with frequent/excessive use. There have also been case reports of paralytic ileus secondary to hypermagnesemia. The patient should be told to expect increased abdominal cramping and flatulence. If they are purchasing the product themselves a 16oz bottle (2 doses) costs <$10CAN. While I found multiple articles mentioning Magnesium Citrate’s use for treating constipation, I could not find any addressing its efficacy or safety in the ED population. Anecdotally, it is stronger than PEG which is why it is a good drug to get things started.

Polyethylene Glycol
It’s a polyether (go-go gadget organic chemistry!) compound aka PEG, GoLYTELY, Miralax and multiple other names that is available OTC and works through a similar osmotic mechanism. It is relatively inert in the gut as it is not metabolized or absorbed and it comes as a tasteless, odorless powder that dissolves in water. As an osmotic laxative, electrolyte imbalances can develop. However, a version called “PEG 3350” is available that has added electrolytes to minimize this risk. It should be taken with the recommended quantity of water to prevent the osmosing of fluid into the intestine from the body. The patient should be told to expect bloating, cramping and flatulence. The Orange Poly-fleet-recommended 4 week supply would cost the patient approximately $20CAN. Long-term use has been studied and found to be both safe and effective.

Fleet Enema
Pop quiz: how many kinds of “Fleet Enema” are there? Unbeknownst to me, the name “Fleet” is attached to every bowel-aid made by the FleetLabs Corporation. This includes at least 4 different enemas (Fleet Saline, Fleet Extra, Fleet Bisacodyl & Fleet Mineral Oil). At my institution, a “Fleet Enema” is synonymous with a “Fleet Saline Enema” and I’ll assume that is what Dr. Wall referred to in his ERCast podcast. This enema also works through an osmotic effect as it consists of a hypertonic solution of sodium phosphate. However, rather than just preventing the absorption of water by the colon, it draws water in. This promotes evacuation, generally within minutes. There are multiple case reports of complications secondary to sodium phosphate enemas including dehydration, hypotension, hyperphosphatemia, hypocalcemia, hypernatremia and hypokalemia. This was most recently discussed in a case series in JAMA published in February of 2012 that recommended using them only in low-risk patients. Unfortunately, I did not find any studies assessing the safety or efficacy of sodium phosphate Fleet Enemas in the ED constipation population. As with any enema, the patient should expect fecal urgency and anal discomfort. Fleet enemas can be purchased OTC for <$5CAN.

In conclusion, with some reservations about Fleet Enemas, I am happy to have a Constipation Cocktail to use as if it were my own. I’d be very interested to hear about the Constipation Cocktails that others are using, as well as any further discussion on the safety of Fleet Enemas. Is everyone still using them? Any thoughts on alternatives?

That’s it for this week! Once again I’d like to thank everyone for supporting my baby of a blog. In particular, thanks to those that tweeted/retweeted my posts, to Mike Cadogan @sandnsurf for the welcoming messages, advice and intro to the blogging community, and to Rob Orman @emergencypdx for the podcast referenced in this post.

Happy Holidays!

Brent Thoma @boringem

Additional references:
Pharmacologic information on the discussed drugs from epocrates

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Brent Thoma

Editor at CanadiEM + Brent Thoma is a medical educator, blogging geek, and emergency physician who works at the University of Saskatchewan College of Medicine. He founded BoringEM and is a senior editor / tech support / jack-of-all trades at CanadiEM.– 1 day ago

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7 Best Enema Solutions to Cleanse and Detox Your Body (With Recipes)

  • People have used enema solutions for centuries to treat constipation, bowel issues, and to cleanse their colon.
  • The benefits range from improving circulation, boosting energy, losing weight, clearing the skin, detoxing the liver, and the list goes on.
  • Keep reading to learn about eight different types of enema solutions and how they can keep your bowels moving and more.

People have used enema solutions for centuries to treat constipation, bowel issues, and to cleanse their colon. But the benefits of enemas stretch even further in the body. Enemas help eliminate toxins that have been stored in the body. The benefits range from improving circulation, boosting energy, losing weight, clearing the skin, detoxing the liver, improving regularity, bowel cleansing, and more.

Disclaimer: Always consult with your doctor before performing an enema at home, especially if you have a serious condition. They may not be suitable for people who are pregnant, breastfeeding, or have certain medical conditions. If you use enemas, do it safely: Use filtered water; ensure liquids are cooled to room temperature; and do not force yourself to hold enema solutions if you are constipated.

What is an enema?

An enema is a procedure where a liquid solution is inserted into the colon via a tube through the rectum. The liquid softens stools in the colon and can stimulate muscle contractions that expel the stool from the colon. Depending on what ingredients you use in your enema kit, you can detoxify heavy metals, reverse gut disease, and boost the immune system. Popular enema solutions include hot water enemas and coffee enemas. They’re most often used to treat constipation or clear out the bowels before a medical procedure

Keep reading to find out what you need for an at-home enema.

See the steps

What you’ll need for an at-home enema

  • Enema kit – You can purchase a stainless-steel enema bucket or a clear enema bag with medical grade silicone enema tubing. Popular enema kits include Medisential Enema Kit, $40, and The Perfect Enema Bag Kit, $18.
  • 2-4 cups filtered water
  • Ingredient of choice from recipes below (coffee, probiotics, herbs, epsom salt, etc.)
  • Medium saucepan
  • Fine mesh strainer and cheesecloth
  • Towels, yoga mat, pillow, whatever you need to be comfortable lying on the floor. You could also settle into your clean bathtub.
  • Lubricant such as organic, unrefined raw coconut oil

How to do an enema

The best time to perform an enema is in the morning after your first bowel movement.

  • Prepare your enema solution and cool to lukewarm (37-40? C or 98-104? F). Be sure your solution has been well-filtered with a strainer and cheesecloth.
  • Prepare your enema kit with the instructions that came with it.
  • Pour your solution into the enema bag or bucket, making sure your clamp is closed before you pour.
  • The bucket or bag should be placed higher than your body, such as on a chair or countertop beside you, or the bag can hang from the shower rod.
  • Prepare the space you will be lying on, then lie on your right side in a fetal position.
  • Unlock your enema clamp carefully to allow the liquid to fill the tubing, then clamp tight.
  • Lubricate the tip of your nozzle using coconut oil and gently insert it 2 inches into your rectum. It may help to keep your right leg straight and your left leg towards your chest to make insertion easier.
  • Unlock the clamp and allow the enema solution to flow. You can pinch your tube to slow it down if there is any discomfort.
    When you start to see air bubbles in your tubing, stop the clamp.
  • Lay in this position as long as you can. You can start out slow and work your way up to 2-15 minutes depending on the type of enema you are performing.
  • Sit on the toilet and release.

Water enema for cleansing the colon

Water enemas are the simplest form of enema you can use. They help clean the colon and soften your stools. Water enemas are often used in hospitals when performing CT scans to distend the area they are viewing to detect what is going on.

Studies on water enemas for constipation and fecal incontinence in children and adults have shown invaluable results for reducing constipation. Using enema additives such as oil or vegetable glycerin significantly increases the rates of continence ability.

If you are just starting to use enemas, this is the best place to start before trying additional ingredients. It is important to use filtered water, as chlorine can kill your gut flora.

How to make a water enema

This is the simplest solution of course. All you need is a 2-4 cups of water.

Bring the water to a boil on your stove top. Remove from heat and allow to cool to a lukewarm temperature. This is important so don’t skip this step.

Coffee enemas for detoxification

For decades, coffee enemas have been used to detox the body and fight cancer; they’re an essential part of The Gerson Therapy for cancer patients, and their popularity is growing. The caffeine in coffee has been shown to open the bile ducts which increases the production and flow of bile. The coffee also stimulates glutathione production in the liver by up to 600-700% above normal levels. Glutathione is the body’s “master antioxidant” and is crucial for detoxification. It also helps to support energy, boost immune function, and bring mental clarity. Glutathione helps to neutralize free radicals, which get dissolved in the bile and excreted from the body. (Learn more about the benefits of glutathione.)

While holding the enema for 10-15 minutes, the blood circulates through the liver 4-5 times!

Functional diagnostic nutritionist and holistic health coach Wendy Meyers, founder of Myers Detox, recently spoke about coffee enemas on this Bulletproof Radio podcast episode, telling Dave that they’re a great way to speed up the body’s detoxification process.

According to Meyers, people with heavy metal toxicity should cleanse with a coffee enema 2-3 times per week. Any more than that can deplete other minerals in the body. If you are healthy, she recommends once per week. Those with chronic illness have done them daily or multiple times per day.

How to make a coffee enema solution

For the coffee enema, it’s imperative that you use organic, mold-free coffee beans, such as Bulletproof Coffee, that won’t add more toxins to your system.

Brew 3 cups of coffee using filtered water and 2 tablespoons of ground coffee. Be sure all beans are filtered out of the solution. Remove from heat and cool completely before using to avoid serious injury.

Herbal enemas to heal and cleanse

Herbal enemas are believed to be absorbed by the intestinal walls and go directly into the bloodstream to support healing and detoxification. There are many different herbs you could use for this enema solution, depending on the benefits you seek. Think of an herbal enema as a more effective and potent herbal tea.

One of the most common herbal enemas you can try is chamomile. Chamomile is known for its calming and relaxing properties. When using chamomile in an enema, it relaxes the colon which can reduce intestinal cramps and spasms caused by gut inflammation. It can also ease anxiety and, if used before bedtime, help you fall asleep faster. People believe chamomile enemas also help with hemorrhoids.

How to make a chamomile enema solution

Boil a quart of filtered water and infuse with chamomile flowers, or chamomile tea bags. Strain the flowers and add another quart of cool water. Allow the liquid to cool until lukewarm.

Garlic enemas for candida and parasites

Garlic is a strong antiviral, antibacterial, antiparasitic, and antifungal. It also boosts your immune system. A garlic enema may aid the body in ridding parasites and killing candida. Garlic also helps remove mucus and toxins from the colon. Because garlic inhibits alpha brain waves and can make it harder to maintain emotional regularity, garlic is a suspect food on the Bulletproof Diet Roadmap. They can also be prone to mold, so choose high-quality garlic, and don’t use regularly. Also, if using garlic in your enema, you may want to avoid being around people as the allicin (what gives garlic its power) will absorb into your colon and you’ll soon be smelling of garlic.

How to make a garlic enema solution

Crush five cloves of garlic and let sit in 1 quart of warm, filtered water for a minimum of 15 minutes. Strain the water, then administer the enema.

Probiotic enema for gut inflammation

By now, you are probably familiar with the idea that the microbiome is a vital part of your well-being — from how your immune system functions to how your brain works. Using a probiotic in an enema solution helps colonize those healthy bacteria in the gut. This gives them a better chance of survival because they are not traveling through the digestive system.

Not only can a probiotic enema help reduce gut inflammation and colonize healthy bacteria, it can impact your brain health too. Read more about the gut-brain connection and how having a healthy gut contributes to less brain fog, better absorption of vitamins and minerals, and a better mood.

In a randomized clinical trial, an enema solution of Lactobacillus (L) reuteri was used for children ages 6-18 with mild to moderate ulcerative colitis. The patients received an enema with the solution nightly for eight weeks. Thirty-one patients completed the trial and the results showed a significant decrease in inflammation in the L. reuteri group compared to the placebo group. Clinical remission in the L. reuteri group was at 31% with none in the placebo group.

How to make a probiotic enema solution

All you need for this recipe is 1 teaspoon of powdered probiotic (Lactobacillus plantarum, Bifdocaterium lactis, and Bifidobacterium longum recommended) and 2 quarts of warm, filtered water.

Mix the powder in the water until it dissolves and use as your enema solution. Perform this enema occasionally to boost your gut bacteria.

Epsom salt enema for constipation

An Epsom salt enema is similar to a water enema but can yield more useful results for cleansing the colon and reducing constipation. The Epsom salts draw more water from the intestine into the colon which helps to relax the intestinal muscles. This is caused by the high amounts of magnesium. The magnesium sulfate also aids in detoxification of the liver.

How to make an epsom salt enema solution

This solution is a quick and easy one. Just add 4 tablespoons of Epsom salts to 8 cups of warm, filtered water. Make sure it is not too hot, and use with the enema kit.

Don’t overuse this enema as it draws out extra water and could cause dehydration. Make sure to stay hydrated when doing any enema solution.

Lemon juice enema for pH balance

Lemons are well-known for helping balance of body pH (not the pH of blood). That is one of the benefits of using lemon juice as an enema solution. It helps to balance the pH levels of the colon and may reduce pain associated with colitis. Lemon juice is a great cleansing enema for ridding the colon of excess poop.

How to make a lemon juice enema solution

Add 2/3 cup of fresh-squeezed (and strained) lemon juice to 2 quarts of warm water.Remember that it needs to be lukewarm and not too hot. Mix it up and use with your enema kit.

To avoid irritation of the intestinal lining, don’t use this enema more than once a week, and hold it in for only a couple of minutes, not too long.

How often to do enemas

If you have a chronic illness, consult your doctor about how often you can safely do enemas. Daily and up to four times a day are often recommended. But if you don’t have chronic issues and are just looking to keep your bowels moving smoothly, once a week is plenty.

Troubleshooting

  • If you have leakage of water, ensure that the nozzle is inserted at least 2 inches into the rectum.
  • If you get a cramp while the liquid is flowing in, close the clamp, turn from side to side, and take a few deep breaths. The cramp will typically pass quickly.
  • Gurgling and squirting sounds are normal. That is your body eliminating toxins.

Precautions

  • If you have a serious condition, consult your doctor before performing an enema.
  • Doing enemas on a regular basis could potentially cause electrolyte imbalances. Make sure you stay hydrated and supplemented as dehydration and loss of minerals can be a side effect.
  • It is critical to ensure that the liquid has cooled to room temperature before doing the enema. If it is hot it can burn the rectum and colon, possibly requiring surgery. This is something many have had to learn the hard way.
  • Do not force yourself to hold in the enema solution or to poop afterward if you’re constipated.

Fleet Enema – What is the difference between constipation and fecal impaction?

Fecal impaction is a condition in which the colon becomes blocked from a mass of stool that can’t be moved by colon contractions. Fecal impaction can cause pain and vomiting, and a person with fecal impaction may require emergency treatment or hospitalization. Fecal impaction is a fairly common complication of long-term constipation in the elderly and bedridden, occurring in about 30% of all nursing home residents.

Symptoms of constipation include:
Fewer than three bowel movements per week
Small, hard, dry stools that are difficult or painful to pass
The need to strain excessively to have a bowel movement
A feeling that your rectum is not empty after a bowel movement
Frequent use of enemas, laxatives or suppositories

Symptoms of fecal impaction include:
Liquid stool (the stool is leaking around the impacted mass of feces and can be mistaken for diarrhea)
Abdominal pain, especially after meals
A persistent urge to move the bowels
Nausea and vomiting
Headache
Poor appetite, weight loss
Malaise (a generally sick feeling

Fleet Enema

Sodium biphosphate and sodium phosphate are forms of phosphorus, which is a naturally occurring substance that is important in every cell in the body.

Sodium biphosphate and sodium phosphate is a combination medicine used in adults to treat constipation and to clean the bowel before a colonoscopy.

Sodium biphosphate and sodium phosphate may also be used for purposes not listed in this medication guide.

You should not take sodium biphosphate and sodium phosphate if you have kidney disease, a bowel obstruction, a perforated bowel, colitis or toxic megacolon, or a history of gastric bypass surgery or stomach stapling.

Do not use more than 1 dose in any 24-hour period. If you do not get any results within 30 minutes after using this medicine, call your doctor before using another dose.

Using too much of this medicine can cause rare but life-threatening side effects on your kidneys and heart.

Kidney failure may be more likely if you have: kidney disease, congestive heart failure, severe constipation or stomach pain, inflammatory bowel disease, if you are over 55, or if you are dehydrated. Using certain other medicines can also increase your risk of kidney problems.

In rare cases, this medicine can cause kidney failure. This effect may be more likely if you have:

  • kidney disease;
  • congestive heart failure;
  • severe constipation or stomach pain, inflammatory bowel disease;
  • if you take certain medicines to treat high blood pressure or heart disease;
  • if you take an NSAID (nonsteroidal anti-inflammatory drug);
  • if you are older than 55; or
  • if you are dehydrated.

You should not use oral sodium biphosphate and sodium phosphate if you are allergic to it, or if you have:

  • kidney disease (or if you have ever had a biopsy showing a kidney problem caused by too much phosphate);
  • a bowel obstruction;
  • a perforated bowel;
  • colitis or toxic megacolon; or
  • a history of gastric bypass surgery or stomach stapling.

To make sure this medicine is safe for you, tell your doctor if you have:

  • inflammatory bowel disease;
  • trouble swallowing, gastroesophageal reflux disease (GERD);
  • heart disease, heart rhythm disorder, recent heart attack or heart surgery;
  • a seizure disorder;
  • recent withdrawal from drug or alcohol addiction;
  • an electrolyte imbalance (such as high or low levels of potassium, sodium, phosphorous, or magnesium in your blood);
  • if you have ongoing vomiting or diarrhea, or if you are sweating more than usual;
  • if you take certain medicines to treat depression, seizures, or kidney problems;
  • if you are on a low-salt diet; or
  • if you have used any laxative within the past 7 days.

FDA pregnancy category C. It is not known whether sodium biphosphate and sodium phosphate will harm an unborn baby. Tell your doctor if you are pregnant.

It is not known whether sodium biphosphate and sodium phosphate passes into breast milk or if it could harm a nursing baby. Tell your doctor if you are breast-feeding a baby.

Do not give this medicine to anyone under 5 years old without medical advice.

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