(by Dr. Kathleen Summers, 7 March 2010)

Google “colon cleanse” and you’ll find a number of marketing sites for products and services aimed at cleaning out the digestive tract.  Almost all the ads say we need to clean out our “cleaner,” that our bodies’ natural systems for removing waste from the body need help from commercial products.

This article describes the yogic approach to intestinal cleansing and explores the history of the colon cleanse as it has further developed throughout the modern era. We’ll look at the natural functioning of the colon, its normal anatomy and physiology. Then we’ll review the evidence of benefit and harm from various procedures and products, including shanka prakshalana.


First Some Clarifications

“Intestinal cleansing” is a general term that describes any process which prods the body into expelling completely all of its already ingested material. The colon is the biggest part of the large intestine, and “colon cleansing” refers only to that part of the digestive tract. There are oral as well as rectal methods. “Cleansing” does not include fasting in this article.

“Colon irrigation”, “high colonic”, and “colon hydrotherapy” are generally used synonymously to describe the insertion of large volumes of liquid through the rectum and deep into the colon to cleanse the digestive tract up to the ileocecal valve, the division between the large and small intestine. They may be either injected with pressure or dependent upon gravity in systems in which containers of liquid are placed above the patient and the solution runs passively “downhill.”

Enemas are smaller volumes of fluid forced into the rectum and distal colon. In the classic yogic approach to an enema, liquid is sucked into the rectum by muscular contractions while the aspirant squats in shallow water. Enemas can only partially clean the colon as they do not reach far enough to clean it entirely.


The Yogic Approach to Cleansing

The first niyama of Yoga is sauca, to be clean and pure. Sauca is to be applied to all the koshas, or layers of the body. Physically we are to be clean, but also our energy, our thoughts, our actions, and our aspirations need to be pure.

By cleansing the physical body, we can affect and influence the other koshas. Our bodies are, after all, integrated systems. Yoga sees the person holistically. If one cleanses the physical body, the energetic, emotional and mental aspects of our being get a cleansing as well. Purifying aligns our koshas to resonate with a higher vibration.

To this end, the Hatha Yoga Pradipika, a book from the 15th century C.E. but derived from earlier undated Sanskrit texts, describes various techniques of physical purification known as the shatkarmas of neti, dhauti, and basti. Neti refers to nasal cleansing and dhauti to the cleansing of the eyes, ears, tongue, forehead, esophagus, stomach, rectum and anus. Basti is the yogic enema, a mild form of rectal washing in which the practitioner traditionally inserts a piece of hollow reed or bamboo into the anus and then, while squatting in shallow water, sucks up the liquid into his rectum through a series of muscular contractions. No water is forced into the rectum by pressure when performing the traditional yogic enema technique.

While the Hatha Yoga Pradipika only describes one dhauti, the swallowing and then removing of a wet cloth, the Gheranda Samhita identifies several others. Vamana dhauti, also called vyaghra kriya and kunjal kriya, is the drinking of salt water followed by the induction of vomiting from tickling the back of the throat with fingers to trigger the gag reflex.

Shanka prakshalana, otherwise known as varisara dhauti, is the yogic intestinal cleanse. It is performed by drinking several glasses of warm salt water. The high salt content in solution acts as a cathartic to stimulate your bowels, and you drink it until you are completely emptied out and only clear liquid is coming from the anus. A physiological concentration of salt water is used, meaning that it matches the concentration of salt water already in your body. In modern medicine, dehydrated patients are given through their veins a salt (NaCl) solution termed “normal.” That concentration is 9 grams of NaCl (sodium chloride) per liter of water, or 0.9%. Roughly it is a tad less than two level teaspoons of fine grain, non-iodized table salt per liter.

After drinking a glass or two of salty water, exercises that are variations of asanas are done traditionally to help stimulate the intestines, but a walk around the yard will also do the trick. Following a few rounds of drinking and exercising, you’ll need to make a visit to the toilet. The salty solution flushes out the gastrointestinal system during a series of evacuations. To be complete, enough salt water needs to be drunk to thoroughly empty the body of all feces, and even the yellowish discoloration of the liquid towards the end of the process needs to completely turn to clear.


History of Intestinal Cleansing and Current Medical Approach

Hippocrates, the father of modern medicine credited with separating superstition and religion from the natural course of disease, advocated intestinal cleansing and enemas in the fourth century BC. Throughout the following years enemas, colonics and other forms of intestinal cleaning have experienced long periods of fashion. Many famous figures have promoted cleansing techniques including King Louis XIV who received over 2000 enemas during his lifetime, some even while holding court. For an interesting short review of enema use throughout history, click here.

Western physicians prescribed colon cleansing and irrigation in the late 1800s and early 1900s for various ailments thought to result from ptomaine poisoning. The absorption of ptomaines, basic organic compounds containing nitrogen that are produced when bacteria degrade protein, was thought to instigate a toxic response in the body as high levels had caused symptoms when injected directly into the blood stream. Some medical doctors took this concept so far as to surgically remove the colon since it was considered a useless appendage that could be causing harm. The medical theory of “auto-intoxication” was subsequently proven incorrect. Science has shown that naturally produced ptomaines are not poisonous, unless perhaps you have debilitating chronic liver failure, but the theory of auto-intoxication lives on and is used by some to support the continued use of colonics to facilitate rapid expelling of all fecal matter before protein has any chance to putrefy.

With scientific evidence to refute the theory of harm arising from undigested material in the colon, western medicine has turned away from prescribing intestinal cleansing for the alleviation of disease. Currently, the only examples of treatment in modern medicine are the administration of activated charcoal in emergency departments to bind toxic amounts of ingested drugs in overdose patients and the administration of magnesium citrate and other laxatives for constipation. Rather than being used as a cure, other oral intestinal cleansers are now only prescribed prior to diagnostic procedures like colonoscopies. Enemas of barium, a material that shows up on X-rays, are used for diagnosing various conditions. Rarely they’re used therapeutically for intussiception, a condition in which the colon rolls up inside itself like a sleeve. Occasionally therapeutic enemas are given for difficult cases of fecal impaction, which is when a hard mass of stool gets stuck in the rectum. Usually those impactions have to be mechanically removed by a doctor’s digging finger, a practice similar to the yogic practice of moola shodhana.


Anatomy and Physiology of the Gastrointestinal System

Ingested food is swallowed from the mouth, travels down a tube called the esophagus, and passes into the stomach. How long food remains there depends on many variables, but the average length of time it takes for the stomach to completely empty is from four to five hours. The contents of the stomach are very acidic, generally with a pH of between 1.5 and 3.5. Comparatively, the pH of orange juice is between 3 and 4, Coca-Cola is 2.5, and battery acid is 1.0.

From the stomach, the liquefied food passes through the pyloric valve into the small intestine, a long winding tube that averages 280 cm, or more than 9 feet, in length. This is the place that virtually all nutrients are absorbed into the bloodstream. Contractions of the loops of small intestine, called peristalsis, propel the food remnants forward. Between meals, when the there is no material to be digested, the small intestine naturally cleans itself of all remaining debris with complicated movements called the migrating movement complex. This movement can sometimes be heard by us, and we call it “growling.”

Once the food remnants have made their way through the small intestine and have passed through the iliocecal valve, they enter the large intestine. The initial segment of the large intestine is the cecum, a little pouch with a worm like projection known as the appendix.

The vast majority of the large intestine is the colon. It’s a great deal shorter than the small intestine, but it is called “large” because its diameter is much greater. The colon surrounds the small intestine and is divided into parts. The ascending colon runs along the right border of the abdomen, the transverse colon runs across the top of the abdomen, and the descending colon runs along the left side of the abdomen terminating in the sigmoid colon and leading to the rectum.

By the time ingested food reaches the colon, almost all of its nutrients have been absorbed. Feces are formed, compounds which are essentially 75% water and 25% undigested food and fiber mixed with bacteria and mucous. The primary function of the colon is to absorb water and electrolytes from the feces and to expel the remainder of the contents as waste. The expelling process is aided by the secretion of mucous that protects the lining of the colon and coats the remaining food remnants to facilitate their quick passage.

There are indigenous bacteria present throughout the intestines that play an important role. They help us to fight the foreign bacteria that can cause disease, and they decrease inflammation and promote a healthy gut immune system. In the colon, bacteria complete digestion of carbohydrates not accomplished in the small intestine. By the process of fermentation they degrade complex carbohydrates, producing intestinal gas in the process. Also, colonic bacteria synthesize Vitamin K, working to supplement that taken in by diet.

For a detailed review of the science of microbes in the gut, click here for a pdf link.


What About “Toxins” in the Gastrointestinal Tract?

As noted, the idea that blood poisoning can occur because of ptomaine production by bacteria in the colon has long ago been disproved, but this “auto-intoxication” theory remains the primary one cited by most colon cleansing advertisements.

Drugs are considered toxins by some. They, and other chemicals such as preservatives and food additives, are absorbed through the walls of the small intestine by passive diffusion. The relatively small amount of any ingested drug or chemical that does not get absorbed and thus reaches the colon is packaged in the feces to be expelled. They don’t hang out in the gut long. Even if they do stick to the epithelial cells or to the mucous barrier of the intestinal lumen, the cells are shed every one to three days taking all toxic accumulations out with them.

Intestinally absorbed drugs, additives, and preservatives are delivered to the liver where they are metabolized and formed into products that can be excreted in the urine. The kidneys also play an important role in the metabolism and elimination of drugs and other ingested chemicals. The liver and kidneys are the body’s natural cleansers. They are efficient, which is why most medicines have to be taken at least once a day to continually fight the body’s tendency to clear them.

Without doubt, we are increasingly being surrounded in our modern day environment by numerous chemicals, and we’re absorbing them through our food, skin, and lungs. For an interesting review, click here. But once those chemicals make their way into the blood stream, they are either metabolized and then excreted by our natural defense mechanisms in the liver and kidneys, or they are stored primarily in our fat cells. No intestinal cleaner will release those stored compounds in fat back into our guts to be expelled.

Some colon cleanse promoters claim that if your feces sinks to the bottom of the bowl, then there must be something wrong, that toxins are present. Actually, doctors ask patients about floating stool when we are worried that they are not absorbing their food in a healthy, normal way. Floating stool can be an indicator that there’s too much fat in it, and that may suggest pancreatic insufficiency or biliary disease. Other malabsorption syndromes can also cause the feces to rise to the surface of the water. If the main food bolus is not absorbed in the small intestine because of disease, then it reaches the colon, where bacteria that work through fermentation, the process that causes gas. Too many gas bubbles dissolved into the feces will make it float. Floating poo can be a sign of celiac sprue, cystic fibrosis, and diseases of bile production or flow.

Richard Anderson, a naturopath, coined the term “mucoid plaque,” and many people are now convinced that this toxic horror may lurk in their intestines (click here for Anderson's take). When ingesting the psyllium and bentonite in his commercial colon cleanse products, the two in combination make a rubber “cast” of the intestinal lumen. Bentonite is, after all, clay similar to that used in ceramic pottery production, which starts out with what amounts to a cast that then needs to be fired in a kiln. There’s no scientific evidence that mucoid plaques exist.

Below is an average colon as seen during colonoscopy. Notice the absence of pounds of mucoid plaque within the lumen.

According to Anderson, mucoid plaque like the one below build up inside our intestines to cause disease.

To date there is no good scientific evidence that intestinal cleansing is beneficial for your health. Then again, it hasn’t really been studied.

Throughout history, from the yogis to the Egyptians and Greeks, people have benefited psychologically from a good purge of the intestines. We’re connected to our guts, and evolutionarily we likely have paid high attention to its function as we foraged for food and considered what to eat. Giving a bath to an area of our bodies that we generally consider “dirty” feels good. It’s like the feeling you get when you take a hot shower after sweating all day laboring on a job. It’s refreshing.

Yoga suggests that a solid physical intestinal cleansing will heal all of our koshas through resonance. It’s a place, a tangible area, in which to work on our mental, emotional and energetic disturbances.

In theory, there might be physical benefits as well. Beyond the fact that an occasional cleanse may clear a bout of constipation, there may be some truth to the claims that it will balance and stimulate the immune system. A large part of that system is the GALT, or gut-associated lymphoid tissue, which resides within the walls of the small intestine. It is one of our biggest allies on the front against foreign invaders like bacteria and viruses. Specialized cells recognize substances that are foreign and potentially harmful and induce a defensive strategy against them. Sometimes this system may malfunction causing allergic defensive responses against benign substances found in food. It’s possible that these tissues may get overwhelmed, particularly in our high consumption culture, and that they may occasionally need a break. Massive, continual antigen stimulation is postulated to be a critical step in the formation of MALTomas, a type of tumor that can evolve in GALT. Patients with MALTomas have a higher incidence of autoimmune diseases, suggesting a link between alterations of the gut lymph tissue and conditions like Crohn’s and celiac disease.

An intestinal cleanse followed by a basic elimination diet that slowly adds back substances such as corn, wheat, dairy, and soy while monitoring for symptoms may help to diagnose food allergies postulated to cause a variety of conditions such as fatigue, chronic headaches, eczema, irritable bowel syndrome, some forms of arthritis, and a minority of asthma cases.


Is There Any Evidence That an Intestinal Cleanse May Cause Harm?

Even in medical settings with trained nurses, enemas and colon irrigation have caused bowel perforations. Tubing, or the high pressure liquid itself, has poked through the thin bowel wall, spilling feces loaded with bacteria into the abdominal cavity leading to massive infection and death.

Serious infections have been passed from one individual to the next by tubing and equipment that was not new or improperly sterilized. In one reported incidence in Colorado at a chiropractic clinic, 36 people contracted ameobiasis. Ten of them required surgery to have their colons removed and one died. Shigellosis is pathogenic bacterium that has been documented as having been acquired by colon irrigation. Many other infections may pass under the radar. Patients don’t always tell their doctors about enemas or colon hydrotherapy they had a few days prior, and if even if they do, there’s no reporting system for cases to be linked and documented.

Ironically, colon irrigation, or the flooding of high volumes of liquid into the colon from the rectum, may actually increase the dissemination and absorption of toxins and bacteria into the body. The pressure gradient will support movement across the bowel wall and into the body, not out the anus. This has been observed scientifically as the movement of lymphocytes into the blood, an indirect sign that more is being delivered across the gut wall, not less.

Orally ingested colon cleansing preparations at least follow a natural route of administration, but that doesn’t mean they may not be hazardous. Whatever you put into your body, be it rectally or orally, there is a risk of side effects.

Various cleansing solutions have been associated with electrolyte imbalances, some leading to subsequent heart attacks. With shanka prakshalana there is a risk of the electrolyte disturbance hypernatremia, a condition in which blood levels of sodium can get dangerously high, at its worst resulting in brain damage and even death.

Western doctors prescribe a high electrolyte solution, GoLytely, which works by the same mechanism as shanka prakshalana, to give a good flush prior to colonoscopies. It also delivers a high salt load to the gut, but it has less total sodium because of the addition of a couple of other chemical agents, primarily polyethylene glycol.

To compare the two, a physiological saline flush in shanka prakshalana contains 7.05 grams of sodium in 1.5 liters. Up to 4 or 5 liters may be needed to achieve the full cleanse (and some teachers recommend even higher salt concentrations than that deemed “physiological”). GoLytely contains 7.14 grams of sodium in the total 4 liters required for cleaning. As a point of reference, the American Heart Association recommends that adults take in no more than 2.3 grams of sodium in one day.

Given that the concentration of sodium is “physiological” in shanka prakshalana and that the cathartic action of the solution causes it to run through quickly, there is a belief among practitioners that little is absorbed. The transport of electrolytes across the gut lumen is more complicated than that, however, and active transport mechanisms may lead to a concentrated amount of sodium in the blood. How long it takes one to drink the salt solution, how much sodium is in it, and how much total volume is consumed will all play a role. Along with individual variation in physiology, these external variations will significantly affect the amount of sodium that crosses into the blood stream. No studies to date have directly measured the serum sodium concentration during shanka prakshalana under controlled conditions.

Numerous other substances are used in commercial cleansing products and most have not been thoroughly studied for safety and side effects. They are not regulated by the government and thus do not have to pass strict tests proving they are not dangerous. Unlike substances approved by the Food and Drug Administration, they have no guarantee of strength, purity or safety. Heavy metals, including lead and arsenic, have been found to contaminate herbal therapies. Effects may vary as the natural strength of the herb varies. Ingesting herbal cleansers with blood pressure and heart disease medicines has led to significant negative interactions.

Senna is an herb commonly used in commercial colon cleanses. In low doses with occasional uses, it is safe for most people, but there are case reports of toxicity. Conditions reported include coma and neuropathy after ingestion of a senna-combination laxative as well as hepatitis after chronic use.

Psyllium containing products are generally believed to be safe. Important exceptions include people with significant pre-existing bowel abnormalities or prior bowel surgery. Obstruction of the gastrointestinal tract has been noted in numerous case reports of patients taking psyllium-containing laxatives, particularly in individuals with previous bowel surgery or when the laxatives were not mixed with adequate amounts of water. Psyllium transiently reduces blood glucose in diabetics and may cause dangerously low levels in those taking certain diabetes medications.

Cascara sagrada, a traditional Native American herbal laxative found in many intestinal cleansing products, is considered safe in low doses with short term use. However, it has been reported to cause severe hepatitis with liver failure, and one study reports a link of chronic use with colorectal cancer.

While an occasional intestinal cleanse may be okay, chronic use of various laxatives has been shown to paradoxically produce decreased bowel motility, producing a dependence upon them. After awhile, you’ll require help to defecate because your own system has lost its ability to regulate normally.

When it comes to intestinal bacteria, the jury is still out. We don’t know how much of either the “good” or the “bad” bacteria are actually removed by these procedures. Individual species of bacteria are known to tolerate various levels of salinity and pH, and compounds such as antibiotics and binders, differently. We do not yet know the way in which each of the nearly 2000 species of bacteria in the intestines reacts to various substances used in cleanses. It’s doubtful a cleanse removes all bacteria as some products promote, but they may alter the ratios. The question is, for the better or worse?


So Who Should Cleanse and How Often?

If you have a medical condition an advertiser is telling you may be miraculously cured by their commercial intestinal cleanse preparation, please be aware that some people just want to make money by giving false hope.

Having said that, if an intestinal cleanse feels right for you, then do it.

Find a program that is safe. Check with your medical doctor first, especially if you have any health problems or take any medications.  Be sure to provide them with a complete list of all ingredients in any commercial product you are considering.

If you are want to try shankha prakshalana, be certain your doctor understands what the process entails. Preferably do this under their supervision so they can advise you of conflicting medical problems or medicines, and so that they may check your electrolytes. NEVER do this alone. Rarely, severe electrolyte shifts may occur that lead to confusion and an altered mental status, and they may ultimately be fatal. To avoid them, try to limit the salt to two teaspoons per liter and drink no more than two or three liters. If you feel thirsty after the procedure, be sure to drink plain water to quench it. It’s your body’s way of signaling that the concentration of sodium in your blood has risen too high. There is no need to wait for hours after shanka prakshalana to drink plain water as is sometimes promoted. In fact, that’s dangerous. Don’t resist your body’s natural thirst mechanism.

Avoid un-natural infusions of enemas or colonics into the rectum, even physiological saline. If you choose to do this, be certain that the tubing and equipment are new and that your practitioner is certified. If needed, use low pressure, preferably gravity dependent systems.

Don’t overdo it. An occasional cleanse may be okay, but too much of a good thing rarely is. How much is too much depends on the method and the materials you choose.

Shanka prakshalana was traditionally done with the change of seasons, presumably at the spring and fall equinoxes. Twice a year is a reasonable schedule. Cleansing with a high salt load more frequently than that, presuming more than the recommended daily amount of sodium gets absorbed, has the potential to lead to chronic problems with high blood pressure and other cardiovascular diseases. Just how often is safe is unknown.


Summary

Throughout history people have had the desire to clean and purify. The cleansing of the intestinal tract, the part of our bodies than contains “dirty” feces, has been a prominent aspect of that desire. Several methods exist, some with more potential for danger than others. While none have been shown scientifically to improve health, theoretical physical benefits may ensue. For many, the psychological effects and the more esoteric benefits to all dimensions of a holistic existence make this a helpful practice.

Shanka prakshalana is an ancient yogic technique utilizing only common non-iodinated table salt and water to effectively clean the gastrointestinal system. In yogic theory, cleaning this aspect of the physical body has beneficial repercussions on the other koshas as well, purifying the pranic and emotional bodies.

Since the early form of a basic practice of colon cleansing was first promoted by the yogis, there have been many changes made in the nature of cleaning solutions with the addition of herbal remedies and invasive rectal procedures. Many of the changes have a definite financial motivation rather than a pure concern for the health of individuals. Costly over-the-counter products and invasive procedures are generally not monitored for harmful effects.

Shanka prakshalana is likely safe for most. As it has not been adequately studied scientifically, the possibility of harmful side-effects like hypernatremeia is a concern. Its practice must be learnt from and should be guided by an experienced yoga teacher.


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Last Updated on Tuesday, 20 July 2010