Colonic Ulcerations Caused by an Enema Containing Hydrogen Peroxide

Abstract

Constipation is a frequent complaint in children (1). Although its etiology is multifactorial-from such congenital abnormalities as Hirschsprung's disease to psychiatric disorders-the child's behavior is likely to be one of the most frequent causes (1). As a consequence, medical treatment must usually be considered a temporary solution while dietary and behavioral habits are changed. Therefore, medical treatment should be as safe as possible. We report the case of a 13-year-old girl with chronic constipation, who experienced severe rectal bleeding after receiving an enema containing 10% hydrogen peroxide. CASE REPORT C. V., a 13-year-old girl, was brought to the emergency ward because of severe rectal bleeding and significant cramping abdominal pain. At first, the familial and personal histories of the patient were uneventful, except for complaints of chronic abdominal pain related to painful defecation. During the hospitalization, the girl was reported to have been sexually abused 2 years before and to have been constipated since that time. A detailed history revealed that the girl was asymptomatic during school holidays, and that the abdominal pain occurred daily at school. When medical help was sought, the consulting physician diagnosed constipation and prescribed an enema with 1 1 of water and 10% hydrogen peroxide. Within an hour after the enema, severe abdominal pain and rectal bleeding occurred, without defecation. A colonoscopic examination revealed hemorrhagic mucosa from the rectum to the splenic angle, with multiple ulcerations. Oral feeding was stopped, but no medication was given. A control endoscopic study after 48 hours showed slight improvement. Biopsies were taken during the second endoscopic examination, and histologic study of tissue samples showed a severely sclerotic lamina propria. The mucosal glands were separated and focally destroyed. Some of the glands contained microabscesses with many neutrophils. The mucosa showed signs of ischemia, but there was no loss of architecture. The histologic findings were in agreement with a traumatic burn. Oral feeding was begun again, and there was a gradual improvement to complete healing verified by clinical, endoscopic, and histologic examination. Unfortunately, 2 months later, the behavioral constipation relapsed. A control endoscopic examination yielded normal results. DISCUSSION Enemas with hydrogen peroxide are popular in alternative medical practices and have been recommended for constipation in family magazines. A water enema is the least effective of 12 colon-cleaning regimens(2). Nevertheless, sterile water enemas provoke ischemic changes in the colonic mucosa of male Fischer rats (3). Treatment by the rectal route must be done very carefully, because the insertion of any foreign object, even an examining finger, may provoke injury(4). Hydrogen peroxide is a useful disinfectant and has been used as a cleaner for endoscopes in a concentration of 3% (5). Using the product as such resulted in instantaneous blanching and effervescence of the mucosal surface (5). Three percent hydrogen peroxide enemas produce chronic ulcers in the rat colon (6) that persist for more than 10 months (7). We conclude that contact between colonic mucosa and hydrogen peroxide results in ischemic lesions of the colonic mucosa. Therefore, enemas that contain hydrogen peroxide are not indicated.