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“Death begins in the colon.”

Perhaps you’ve heard this little bit of “alternative medicine” wisdom. Oddly enough, I had never heard it until well after I had become a surgeon (although my first thought upon hearing it was that it would make a killer name for a rock band or a blog). That’s when I began encountering claims that seemed to indicate that constipation was the most evil thing in the world, something that must be avoided at all costs. Naturally, I wondered just what the heck was meant by this bit of “wisdom.” What, I wondered, was it based on? What, I wondered, was the purpose of it? To answer this question, recently I decided to go back and review what people say about colon health:

Have you ever considered this simple question: Are you clean inside?



Well, no, not really. I know that, like every other human, I’m most definitely not “clean inside,” if by “inside” you mean my gastrointestinal tract and upper respiratory tract. As is the case for everyone, my colon is crawling with hundreds of species of bacteria, where the most common species (E. coli) makes up only 1% to 2% of the total bacterial count and by the time the stool makes it out around 10% of its mass is made up of bacteria. We humans aren’t even “clean outside,” either, given the bewildering variety of bacteria that live on our skin and mucous membranes. Any part of our body that comes into contact with the outside world, whether it be skin, pharynx, or gastrointestinal tract, is most definitely not clean. Indeed, the variety and rich ecosystem of the bacteria living in various ecological niches in your body and mine actually makes it more difficult for pathogenic bacteria to gain a foothold and cause disease. Your little critters living all over and in your body are your friends most of the time (one exception being when your immune system is suppressed).

And that’s completely normal. Unless you’re a believer in colon cleansing, of course. If you believe in colon cleansing, the concept of commensal bacteria living within you is impossible to bear:

Of course you take care of the outside: You shower, brush your teeth and wash your hair on a regular basis, but do you clean yourself inside? In this modern, toxic world it’s becoming a simple fact of life that our colon (the ‘sewer system’ of the body), liver and other organs also require regular cleaning. Just like a car requires an oil change periodically.

It all sounds perfectly reasonable, doesn’t it? We clean other parts of our body regularly; so why don’t we all clean our colons as well? Here’s the concept behind colon cleansing in brief, so that you don’t have to wade through websites that I’ll be linking to (unless you really want to, that is). Colon cleansers claim that, thanks to our degenerate low fiber Western diets, the colon does not empty itself out properly when we defecate, and that we therefore build up layers of stool on the insides of our colons that slowly poison us, leading to all sorts of disease. True, low fiber diets may be responsible for health problems, but not in the way described by these “alt-med” mavens. But, here, don’t just take my word for it:

You need internal cleansing, unless you’ve been a vegetarian since birth and lived on a pristine island away from pollution growing your own food. (Otherwise how could you bear the thought of having stuff like you see in the picture INSIDE YOU?!)

I warn you in advance that this is not the sort of thing that those who are easily grossed out should look at, but this is the sort of picture that they’re talking about. Don’t click on the link if you have a weak stomach, as there are many pictures of the “results” of colon cleansing. (I’m particularly amused, although also somewhat disgusted, by the series of photos near the end in which the proud colon cleanser has carefully arranged the results of his efforts around the rim of the toilet bowl.) It is then asked:

So what is the root cause of most digestive ailments? Look at the picture below. How would you feel if long pieces of old toxin-filled fecal matter were stuck to the inside of your colon for months or even years? Would you feel constipated, bloated and lethargic? Would your bowels be irritated by this debris day in and day out causing what we call IBS? Just think about what else toxic build-up like this can cause? Stomach pain and constipation? Fatigue, gas and bloating? Headaches and indigestion? Weight gain and a large protruding belly? The list is almost endless.

It is–if you don’t know anything about how the colon works. For one thing, if you peruse sites pushing colon-cleansing products, one thing you will quickly find is that many of them seem to have a rather unhealthy obsession with bowel movements. Indeed, you will learn that a “healthy colon” should have at least two to three bowel movements a day, or, as I’ve seen more than once, “one BM for each meal eaten” and that they must be soft and light brown. Some sites go even further and claim that, not only should your feces not stink but they should float. Here is one example:

Many conventional doctors are under the misconception that having a bowel movement every two or three days is sufficient and even “normal” for some. This is a dangerous fallacy! A person with a healthy colon should in fact have two to three bowel movements per day, or one for each meal eaten. Elimination should be complete, fast and easy. The stool should be light brown in color, long and large in diameter, “fluffy” in texture and floating on top of the water. There should be no offensive odor and it should break apart with the toilet flushing. Going to the bathroom once every few days, sitting there straining for half-an-hour and passing black, hard “pebbles” that drop to the bottom is not only abnormal, it is also serious trouble waiting to happen.

This is, of course, utter nonsense.

In fact, most of the time, stool shouldn’t float. As strange as it may seem, physicians, particularly surgeons, often ask patients suffering from abdominal or digestive complaints that very question: “Does your stool float or sink?” Patients look at us as though we’ve lost our minds when this question is asked, but the question has a purpose: If your stool floats, it may have too much fat in it, which may mean that you’re not absorbing enough fat, which can be a sign of various diseases. It could also mean that you’re not absorbing the nutrients other than fat in your food, thus letting more nutrient- or fat-rich material reach the colon, where your friendly neighborhood commensal bacteria feast on it, producing–you guessed it– gas bubbles in the stool. These gas bubbles make the resultant stool less dense overall and thus more likely to float! Indeed the proverbial floating poop can be a sign of celiac sprue, cystic fibrosis, biliary disease resulting in inadequate bile flow to the bowel, or GI infections. Moreover, if you eat any red meat at all, your stool won’t be light brown, nor should necessarily it be. It shouldn’t be black, of course (which can be a sign of GI bleeding, as digested blood turns stools black), but it doesn’t necessarily need to be light brown either. Indeed, if your stool is too light (“clay-colored”), it might be a sign of liver, pancreatic, or biliary disease, and the reason surgeons often ask it is that floating stool can be an indication that gallbladder surgery is required. Floating stool may mean nothing at all, and healthy people can have them, but it can in the proper clinical situation be indicative of serious disease.

Some websites even go further, making incredibly silly observations like this:

If you’re not eliminating approximately the same amount that you are eating, then what do you think happens to the remainder? The accumulation of old, hardened feces sticks to the colon walls, inhibiting its proper function of absorbing the remaining nutrients from the fecal matter. Instead it is forced to absorb toxins from the build-up and from the parasites that make this debris their breeding ground. The passage through which the feces are forced to travel is also greatly reduced in diameter so the stools become much narrower – even as thin as a pencil sometimes.

The first silly part, of course, is the claim that you must eliminate “approximately the same amount that you are eating.” Why on earth would anyone think that that must be true? After all, what happens to the part of the food that we actually use for energy? It’s digested into its component sugars, fats, and amino acids and absorbed. The second silly part is those evil unnamed “toxins” again, the ones that are, according to the “detoxifiers,” the cause of basically all disease. They’re probably unnamed because it excuses these sellers of colon cleansing and “detoxifying” products from having to provideany actual evidence for their claims. Here’s a more pointed example of such thinking:

It may be said that almost every chronic disease known is directly or indirectly due to the influence of bacterial poisons absorbed from the intestine. The colon may be justly looked upon as a veritable Pandora’s box, out of which come more human misery and suffering, mental and moral, as well as physical than from any other known source.

My first reaction to this sort of thinking was: Every chronic disease? This is the sort of thinking that leads paragons of “alternative” medicine like Hulda Clark to proclaim a liver fluke as the cause of all cancers. Believe it or not, there is actually a Guild of Colon Hydrotherapists, and this is what it says about the colon:

The colon is a sewage system but by neglect and abuse it becomes a cesspool. When it is clean and normal we are well and happy; let it stagnate, and it will distill the poisons of decay, fermentation and putrefaction into the blood, poisoning the brain and nervous system so that we become mentally depressed and irritable; it will poison the heart so that we are weak and listless; poisons the lungs so that the breath is foul; poisons the digestive organs so that we are distressed and bloated; and poisons the blood so that the skin is sallow and unhealthy. In short, every organ of the body is poisoned and we age prematurely, look and feel old, the joints are stiff and painful, neuritis, dull eyes and a sluggish brain overtake us; the pleasure of living is gone.

In other words, if you don’t poop the way colon “hydrotherapists” think that you should, the pleasure of living will be gone. Really.

And here’s more:

When the colon does not do its job, all organs suffer. Uneliminated waste material soaks back through the colon into the lymph glands throughout the system. When these glands become overloaded with toxins, disease will set in. Cellular mutation will take place and abnormal growth will form in the body. It is not hard to understand why the sensitive mammary glands are one of the first targets for disease. One of the largest sites for lymph elimination is the underarm. If the lymph is congested, the toxins flow into the mammary glands. The breast will also take on toxic overload when underarm toxic elimination is decreased through the use of antiperspirants. Lymph is also dumped into the colon wall. If the colon is backed up with debris, lymph congestion cannot be relieved. It will back up within the lymph system causing even further congestion, and affects the liver. The toxins taken up by the liver are excreted as part of the bile. When the bile toxins become excessive, the bile backs up into the intestine and the result is nausea. […] Toxins and poisons are given off by the body but may become dry and hard as the material becomes glued to the pocket of the colon wall. A person must do a colon cleanse to get this matter out. Most people have a transit time (for food to completely pass through the intestinal tract) of seventy-two hours. After a colon cleansing, however, this time is reduced to twenty-four to forty-eight hours (digestion and elimination). An English doctor tested a lady by giving her a marker pellet. Every day she moved her bowel after taking the pellet, but it took one week for the marker pellet to come out. Even though your bowels may move every day, you can still be constipated.

So what’s the answer? Super-regularity above and beyond the call of duty, or, as I call it, regularity über alles! It’s not enough to have a bowel movement a day. Oh, no. That’s for putrefaction-poisoned wimps. To be healthy, if you believe these colon detoxification mavens, you simply must poop way more often than that, helped along by a wide array of enemas, herbal laxatives, and purgatives. In other words, you have to do whatever it takes, and what it takes can be pretty extreme. Look at these testimonials for Colonix, a typical product designed to remove all these evil humors, if you don’t believe me.

Of course, this stuff must work, right? Otherwise, how could we see such glowing testimonials? I still remember a truly hilarious testimonial (in a rather disgusting sort of way) that I saw a couple of years ago. Unfortunately, the original is gone, but it still lives on on the Randi.org forums. As I recall the original quote, the person giving the testimonial was ecstatic over having 14-20 bowel movements a week and sometimes as many as three to five bowel movements a day, and exulted:

We are having awesome adventures in the bathroom.

That’s just way too much information, I’m afraid.

Having a bowel movement three to five times a day may be desirable if you’ve had a total proctocolectomy and had to have an ileal pouch reconstruction, using a small bowel loop to replace the reservoir function of the resected rectum, but that’s only because these patients can sometimes have as many as 10-12 bowel movements a day after such surgery. Trust me on this. They don’t like it. They don’t like it one bit.. Sometimes they don’t like it so much that they ask their surgeon to convert them over to a permanent ileostomy, for easier management. The bottom line is that such patients tolerate having 3-5 bowel movements a day in return for not having to wear a bag, not because they think it’s such a great thing to have to go to the bathroom that often.

But is there anything to all this? Does decaying, nasty feces stuck to the insides of your colon poison you with toxins and lead to disease?

Not really, except under very uncommon circumstances.

First of all, the bacteria decried by colon cleansers are in reality completely normal and do not “poison” their host, except occasionally, such as when a new strain (such as pathogenic strains of E. coli that cause food poisoning or simply bacterial strains that “don’t belong” and cause travellers’ diarrhea). They are even beneficial in that they help with the breakdown of bile salts in the stool, among other things. Indeed, one of the reasons that antibiotics often cause diarrhea or a secondary infection known as Clostridium difficile colitis (which can be life-threatening) is because antibiotics kill the normal bacterial flora of the colon, allowing pathogenic bacteria to grow into the niche left behind by the dead normal bacteria. Second of all, yes there are parasitic diseases of the colon (Giardia or entamoeba, anyone?), but worms and gastrointestinal parasites are relatively uncommon causes of colon disease in the developed world. Third, as a surgeon, I can tell you from simple experience operating on the colon that hardened feces do not accumulate on the walls of the colon as the colon cleansers claim. Any gastroenterologist who does a lot of colonoscopies could tell you that too. Even in disease states in which colon motility is impaired, we generally do not see the feces “caking” on the walls. Even in the case of mechanical obstruction by, for instance, a colon or rectal cancer, what we see is lots of fecal matter fairly evenly distributed in the lumen of the colon.

But what, you may reasonably ask, is all that nastiness that colon cleansing websites so proudly display as evidence of the “success” of their cleanses? One thing you will find, if you look closely at the ingredients of many colon cleansing products, is that many of them contain bentonite clay. This clay is touted as having been used by indigenous tribes for many centuries (the fallacy of ancient wisdom–my favorite!) and as a “natural” laxative. What it really is is an absorbent aluminium phyllosilicate clay that expands in the gastrointestinal tract as it absorbs fluid. Often the bentonite clay is combined with psyllium, which is often used as a bulk-forming laxative. The beauty of this, as far as sellers of colon cleansing products go, is that bentonite clay is responsible for those disgusting rope-like stools that are touted as “evidence” that people’s colons are coated with layers of disgusting waste that is “poisoning” them. Such stools consist of the clay expanded by the liquid from the gastrointestinal tract, plus the bulk formed by psyllium, all coated with feces. Thus, the product itself produces the very condition that it claims to treat! I sometimes envision experienced and skillful con men tipping their hats in appreciation and respect when they learn this little fact about colon cleansing products.

The problem all boils down to an obsession with “toxins,” “waste,” and “putrefaction.” Colon cleansing mavens seem to view their own waste products as somehow inherently “harmful,” obsessing about them in much the same way as General Jack T. Ripper obsessed about his “purity of essence” in Dr. Strangelove: Or, How I Learned to Stop Worrying and Love the Bomb. Indeed, if you hang around on enough the “right” discussion forums, you will get the distinct sense that they find the very thought that they have feces accumulating in them all the time, loaded with bacteria, to be hateful and impossible to bear. This attitude is, of course, odd, to say the least, given that the very function the colon evolved over millions of years to do is to remove our digestive wastes safely and efficiently, extracting water, electrolytes, and what little other nutrients are left over, before depositing the waste into whatever receptical its owner sees fit to use. For the vast majority of people, whether it does it three times a day or once every three days does not matter much. Worse, in the cases of people who do have a real parasitic infection, all the purging in the world won’t get rid of the critters causing the disease, no matter how many times a day one drives oneself to go. Only appropriate drugs to kill the parasites can correct the problem.

In any case, constipation is determined more by the hardness of the stool and the difficulty a person has expelling it, rather than any arbitrarily determined frequency of bowel movements. Mild constipation can be treated with fiber-containing laxatives, although occasionally a purge with magnesium citrate or even GoLytely may be necessary for very severe cases. However, in general, stimulant laxatives, enemas, and purgatories can mess up a colon up really bad and should be avoided when possible. They can result in dependence on them over time just to be able to defecate. Another favorite colon cleansing method, colonic irrigation, has risks, too, including excessive fluid absoption leading to electrolyte abnormalities and, if too much pressure is used, it can even cause colon perforation! During my residency, I encountered a couple of patients who had abused laxatives. They were truly miserable, and totally depended on their laxatives just to have a normal bowel movement.

In reality, there is a great deal of similarity between the concept of “autointoxication” and certain religions. In the case of “autointoxication,” the body of the person with a disease is viewed as “unclean,” contaminated by itself, and, of course, in dire need of cleansing. Does anyone see the parallels to Christian doctrine? Consider: According to Christian religions, people are inherently “unclean” because of original sin that, no matter what they do themselves, they cannot remove. (Only God can.) Now consider the beliefs that drive colon cleansing, in which adherents believe that they are inherently unclean, full of “putrefaction,” and being “poisoned” from within through the absorption of “toxins” (whose exact identities are conveniently rarely, if ever, specified). They believe that they need something to “cleanse” that uncleanliness before they can be well. Compare that to not just Christianity, but to a number of religions in which adherents must “cleanse” themselves of evil and putrefaction by various purifying acts and rituals. This should not be surprising, as the beliefs that drive people to cleanse their colons by various means are not based in science, but rather seem to be more religious or quasireligious in nature.

One thing’s for sure. Colon cleansing is a dubious and almost always useless procedure that shows no signs of going away. There is a thriving market offering an amazing number of products that claim to be able to rid you of all that nasty fecal buildup that doesn’t exist. It may be the most obvious retort in the world for such woo, but the very nature of these sorts of products makes it difficult to avoid–nay, it demands that I not avoid–saying that colon cleansing is a load of…well, you know.