Back-flow past the Ileocecal valve

Greetings,

Does anyone have a sense of how much pressure who have to exist in the colon before an enema would back-flow past the Ileocecal valve into the small intestine?

I am not trying to do this, but rather AVOID doing this, particularly while receiving large enemas.

Also, if say, a normal saline enema were to go into the small intestine, what danger would it pose?

Thanks in advance.

Rob in Central MA

While holding a two to three quart enema, I like to lie face down on the floor. This seems to force fluid into the small intestine. The only effect has been delayed expulsion. I have only done this with plain water though.

What danger? None, really, as long as your sane about pressure and temperature and all that. I'm not a doctor though, and every time I get water that high it makes me extremely nauseous, so I avoid it like taxes.

There's a pressure point you can push on that will close it off, one of our resident nurses has mentioned it, and I would like to know more too. Doing so would serve to help increase the pressure in your colon though, which is usually a bad thing.

This has happened to me a couple of times. I didn't really try to get the water that high, but it seemed all of a sudden my small intestine filled up and I got some water into my stomach. I threw up a bit, but had no problem. I was a tad uncomfortable, but I didn't do any damage to myself. For me I could feel any gas in my system or air bubbles moving up and I burped the air out of my stomach.

Some people want this to happen to them, so they allow the pressure to build.

I would think that doing this over and over, probably cause some damage to your system.

Hi rob i am not a doctor but from what i have learned reading poasts on this sight getting enema past that valve while not a good idea is probly not life thretaning especaly if your large bowel is resnobly clene the small intestine is almost sterle so if your not clean you would be forsing all those nasty bacteria back where it does not belong some report vomiting and nosia also hope this helps lee

I read that the average colon has a capacity of about 2 to 2 1/2 quarts. Beyond that quantity, the valve does open. That's how you get up to 4 quarts with these large volumes mentioned on this site. You know when it opens, as you are struggling and panting to take a little more, and then all of a sudden, you feel the flow going, and the bag empties fast again and there is a big drop in pressure. You typically do get dizzy and sometimes nauseaous. If you completely fill the small instestine, then next is backflow into the stomach when you will likely vomit. I never got that far however. Also, what goes into the small intestine will not be expelled, but will come out as urine excretion. A downside also with water backing up into the small intestine, is there will be bacteria in your blood, if you have a blood test a day or two after.

I once read of a procedure that used a long series of massive enemas to literally clean someone all the way out - to the point where they were throwing up solution. This doesn't seem very safe to me - in addition to getting bacteria where it shouldn't be, I think there is the danger of absorbing too much water - or alternatively dehydrating the recipient if the saline balance is wrong.

I have read a post of a barium enema where you are complete clean out with laxative. The person is taken to the x ray room given pain med, the barium enema is started the large bowel was filled x rays taken that is about 3-3 1/2 qt. The barium enema bag re flied the enema restarted the stomach is push around the barium is being pushed around the small Bowell begin to fill the person need to be held down or restraint down because it is very painful the x ray are taken if the person is given more enema the person will vomit. The person after all the x rays are taken the bag is lower & the barium is run back into the bag the person is taken to expel the barium enema. When the person is taken back to there room is given a large laxative to get the barium out. I read that this was done a lot years ago. I have been given barium enema the first one over 40 years ago I was in my 20, I had been given many enemas growing up but the first barium enema bag full I asked the women are you going to put all of that barium in me she smiled said most of that bag of barium will go in you we see what the x rays say! The women put the tube in me fill the bubble up started the barium the doc said more & more my stomach was very full, I looked at the bag she was wright the bag was almost not anything left. The barium enemas I have Been given are about the same but I knew what they were going to do so I knew about how long it took the cramps after the x ray the enema was run back in The bag that barium enema was over!!!

Speaking as a someone with medical qualifications and considerable experience in this area, a barium enema (Introduced via a tube in the rectum)is only ever used to examine the colon not the small bowel.

It is not uncommon for a small amount of barium to leak past the ileocecal valve into the ilium - part of the small bowel by just a couple of inches but that's the extent of it.

Never would this be deliberately done as part of an examination.

The large bowel will indeed hold a very large volume without any leakage past the ileocecal valve and what "hometool"so well described (suddenly being able to accept more solution)is most likely a spasm in the bowel resolving and then allowing flow to a further portion.(? the caecum)

There is however another x-ray examination known as a small bowel enema, this time however a tube is inserted via the mouth and passes through the stomach into the duodenum. The barium is injected and passes along the length of the small bowel in the normal direction. I don't think this would be nearly as much fun.

I hope this is not just useless information.

I'm with all full. There is a lot of lack of medical knowledge plus a certain lack of common sense

I learned the small vowel is 21 ft long curled up like French horn. It would take a lot of water to get that far.

Generally, if it hurts (depending on your tolerance) stop doing it. Mom nature will catch up with you

Retrograde small bowel filling was suggested by a radiologist many years ago. With great difficulty he was able to get small amounts of barium into the distal ileum. No one does this routinely however. To think that fluid can get all the way to the stomach is totally ridiculous. Bacteria can get into the distal small bowel with a colonic obstruction but usually presents no problem when the obstruction is relieved.

@liquidsky and allfull - I'm afraid that's not quite accurate, although it's an understandable omission, as it's not a very well known bit of medical history. The radiologist you refer to , liquidsky, was called Rosoe E. Miller and I have his paper entitled "Complete Reflux Small Bowel Examination" published in Radiology in 1965

http://pubs.rsna.org/doi/abs/10.1148/84.3.457

I have included a quote from this here.

"With proper equipment we have also found retrograde flow to the duodenum to be the rule rather than the exception. In our first 10 cases barium reached the duodenum in all and refluxed 9 times into the stomach. We now stop as soon as the duodenal bulb is observed, or after 4,500 cc of suspension is given. We have visualized the stomach after only 2,000 cc of the contrast medium. Obviously, this method will not work in those few patients in whom reflux cannot be made to occur. In our present series, we have failed to overcome the ileocecal valve only 3 times in over 75 cases. We believe the ability to achieve reflux depends somewhat upon the experience, competence, and diligence of the examiner."

Interestingly he mentions later on that he first had the procedure performed on himself to see whether it was tolerable, and noted that it was less painful than cystoscopy, but that it was advisible to have the gown tied loosely as a tight gown could be "quite distressing" due to "considerable abdominal distention".

If you would like a more recent reference here is a link to a google books preview of Merrill's Atlas of Radiographic Positioning and Procedures, published this very year. It includes a short description of the (largely obsolete) procedure, together with an example radiograph of someone who has undergone it.

https://books.google.co.uk/books?id=xzAxBgAAQBAJ&pg=PA141&lpg=PA141&dq=complete+reflux+small+bowel+examination&source=bl&ots=q6whSLOhpc&sig=bBUj-nkrnKoUhjjwp8RzYq3_h4M&hl=en&sa=X&ved=0CFMQ6AEwCGoVChMIrPDL2r7ixgIVwjI-Ch1zTQQq#v=onepage&q=complete%20reflux%20small%20bowel%20examination&f=false

Now whether this is a remotely good idea without close medical supervision, that's another question entirely.

Ah yes, I stand corrected. Yet this procedure is never used today. Why examine the small bowel in a retrograde fashion when barium or other liquid contrast media can be swallowed easily?I did read the original article too but forgot the details. Small bowel follow through studies have been replaced with CTs in evaluating the small bowel. I do admire Dr Miller for his courage in performing this on myself. I'm reminded of the inventor of the Swan Ganz pulmonary artery catheter who threaded one into himself and then walked up a floor to have it's position confirmed by X-ray.

I think Prof. Miller claims that you can get more even and complete filling with contrast using the retrograde method. I agree that this method is totally obsolete however.

The most interesting thing I note from the paper is that complete filling of the small and large intestines was almost always obtained with a volume of 4500ml, which is just under five quarts, with the enema bag never raised more than 3' 4" above the table. Because of this I am inclined to conclude that in the majority of 4+ quart enemas some filling of the small intestine occurs.

Of course that's not certain - it's possible that the barium sulfate suspension is more effective at opening the ileocecal valve than "recreational" enema solutions for example.

How can a thicker solution penetrate the ileocecal valve more easily than water? Besides, water based contrast is routinely used without such reflux. Dr Miller had to use very high pressures to achieve this and according to his account it was a bit of an arduous process.

How can a thicker solution penetrate the ileocecal valve more easily than water? Besides, water based contrast is routinely used without such reflux.

I have no idea, but if there is anything that studying biology has taught me it's that one shouldn't necessarily trust common sense. If getting past the ileocecal valve was a purely mechanical process, I would agree with you, but there could be something different about how the valve responds to the different solutions. I'm not saying it's likely - I'm saying it's a variable that hasn't been accounted for.

Dr Miller had to use very high pressures to achieve this and according to his account it was a bit of an arduous process.

I agree with you about the arduous process bit, but I disagree with you about the high pressures. The bag was raised to a maximum of 3' 4". That means a maximum pressure of approx. 1.5psi, not accounting for hose friction which would tend to lower the pressure. That's lower than the cutoff pressure used by some colonic irrigation practitioners (2 psi), and it's lower (judged by bag height) than many of the accounts of large enemas on Zity. That's unless he was using abdominal massage/compression to raise the local pressure in the cecum, which he doesn't mention.

Actually, back in the 19th century (those days of medical horrors...), I read an account of a doc who cured a 12-year old girl's intussusception with a huge enema. Bag was hung very high, inflatable used (I think), and then several gallons of water injected at very high pressure. Eventually, the girl vomited that water (UGH!), but her other problem was cured.

Since this was in a medical book published for the medical community, I'm not inclined to doubt it. But...OWWW! I don't imagine us older folk would tolerate that, since diverticuli are almost always present in older people in our generation. I used to take about 4 quarts fairly easily, and I know that some leaked past the ileo-cecal valve, because I could feel things sorta "giving up" inside.

Now, 2-3 is a bit more of a challenge than 4 used to be, since I don't do enemas quite as often.

I'm returning, though, to the "more is better" and "more often is best" belief of my earlier years. I liked the way I felt. In my case, a large enema is the best enema. It's how I like to give them as well (I like giving LOTS better than receiving...)

--Doc.

Intussusceptions are always treated with barium enema decompression today unless there is evidence of perforation. This is always attempted in adults and children as a first measure even if surgery is necessary later. Intussusception

is an increasingly rare problem because of antibiotics which minimize swelling of Peyers patches. These immunologic structures swell in response to infection. They act as a lead point for the intussusception.

My colon holds just a bit over 2 quarts the small intestine holds a bit less than 2quarts its very easy to open the ileocecal valve as it is really just the same as the outer vagina lips the stomach does have a good check valve and you will vomit if you force fluid past it unless you have mega colon no human colon that i know of holds 4 or 5 quarts some must be flowing into the small to hold that much the small will take much longer to empty

In most cases the fluid in the colon is not refluxing into the small bowel. X-rays with barium and water soluble contrast routinely show no retrograde flow through the ileocecal valve. To get such reflux required a lot of pressure and special technique. To evidence is the lack of small bowel opacification in the majority of BE studies. Also the ileocecal valve is not one bit like the vulva. It's a sphincter like the anus. Also the volume of barium for a BE is typically four to five liters not two.

I feel slightly bad that I have to do this, because you're normally spot on the money, but:

In most cases the fluid in the colon is not refluxing into the small bowel. X-rays with barium and water soluble contrast routinely show no retrograde flow through the ileocecal valve. To get such reflux required a lot of pressure and special technique. To evidence is the lack of small bowel opacification in the majority of BE studies.

That's not true: "In several large series, reflux of barium into the terminal ileum was recognized at single-contrast barium enema examination in 90%–92% of patients...In our study, the ileocecal valve was visible at double-contrast barium enema examination in 91 (86%) of 106 patients. However, reflux of barium into the terminal ileum could be demonstrated in only 75% of patients in whom the valve was identified." (http://pubs.rsna.org/doi/full/10.1148/radiol.2271020396)

Also the ileocecal valve is not one bit like the vulva. It's a sphincter like the anus.

Agreed.

Also the volume of barium for a BE is typically four to five liters not two.

"A standard mixture used for single-contrast barium enemas ranges between 15%-25% weight-to-volume (500 cc of barium sulfate is mixed into 1,500 cc tepid water to produce a 12%-20% solution)." (http://www.auntminnie.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=55654). Heck, standard barium enema bags (EZ-EM brand) only hold two and a half litres total.

Oh Apollo I forgive you. How do you know so much? Radiologist or X-ray technician? You're very well informed.

Thanks, although actually I'm just a biomedical scientist (in a totally unrelated field). This gives me good literature research skills, and I like to apply those skills to my hobbies. I was interested in the physiology and mechanics of enemas (e.g. what volumes and pressures are realistic and safe), and the information out there is a bit sparse, except concerning barium and other contrast enemas, so I did a fair bit of reading around the subject.

I can get a bit obsessive about it - I have plans to build a pressure-temperature-volume data-logger for enemas, and I would love to own a real ultrasound machine for play exams (I can't justify the cost at the moment though).

As for knowing the volume of a barium enema bag - I used to use one as my primary enema bag, until I upgraded to a 4 quart silicone bag.

I had the intussusception (sp) procedure done on me after I was struck point blank in the abdomen by a soccer ball during a game and that was flat out the worst thing I ever experienced. The injury caused a folding over of the trans (sp) section of my colon up fairly high and put me in real danger as the pain of the strike grew worse over the next 48 hours. To cure the problem, the radiologist connected two ezem bags with a Y connector and filled both up to their absolute limits, about 5 liters total and attached an inflatable nozzle to the end, elevating the IV stand to initially 3 feet off of the table. The radiologist warned me before starting that this was really going to hurt and that the female radiology tech would be managing the flow while two male techs would hold me in place when the pain reached the point of not being tolerable.

Rather then giving me a gown to wear they gave me a towel to wrap around me since the gown would obstruct the radiologist's ability to directly visualize and manipulate where the twisted part of my intestine was. I changed out of my clothes and wrapped the towel around me and walked into the xray lab where the four of them were waiting and had me get on to the platform on my knees with my chest on the table and my head resting on a large pillow, my bottom peaked into the air with my feet over the edge of the table. The two male nurses stood next to the table on both sides. The doctor was to one side watching the monitor about to begin.

I heard the nozzle and hose be removed from the IV stand and the squeezing of the jelly in two short bursts. I need to do a rectal exam first the female tech said and I felt her separate my butt cheeks and then touch my anus with her finger and then deftly slide it in, twisting as she went. Then she removed her finger. Ok now time for the nozzle and she slid this seemingly very large nozzle in and then I felt like I had to poop from the pressure. I squirmed and she said that is the balloon that I inflated to keep the fluid in. I was suddenly very uncomfortable and felt trapped. The two male techs inched closer on each side of me.

Then the radiologist said Lets start and I heard a click and felt a steady rush of cool fluid inside. Can you raise the IV stand by 12 inches I heard the radiologist say and I saw one of the male techs disappear behind me and heard the stand raised upward. This is starting to hurt I said and radiologist said we have just one liter of fluid in you right now so you are going to have to just bear this out otherwise you will have to have intestinal surgery to correct this.

The pain was growing rapidly and I was still on my hands and knees with my head on the pillow but I was starting to squirm. The two male techs then put their hands on my, on my back and thighs and held me in place. We aren't going to let you move until the doctor says the intestine has straightened out. They had a very tight grip.

By now I was starting to cry the pain was the most severe I had ever felt and the female tech said we are about halfway in you have a little over 2 liters in. Your colon hasn't started to distend yet the radiologist said as he watched the proceedings on the monitor. Apparently at about 3 liters I was pleading for them to stop and the radiologist directed the tech to extend the stand to 5 feet over the table. I thought I was going to pass out from the pain.

When they got to 4 liters I couldn't stand it anymore and the two male techs were having a problem restraining me so they stopped for a minute with me about to pass out. They brought in a third very muscular female tech and had me move from the knee chest position to laying on my right side. The three techs then clamped me down pinning me at my thighs, waste, and shoulder. I pleaded for them to stop but the radiologist said we are almost there. I heard the click and felt this huge spike in pain as the 5th liter was driven in. Your colon is now distended the radiologist said and I need you to roll on to your back. I could barely do this as I looked 9 months pregnant.

Now I need to massage the area where the injury is to get out the kink and he touched where the trans section is and instructed the female tech to restart the flow. I think I passed out just as they raised the IV stand to the ceiling and released the fluid, the hose snaking out of my bottom up to the bags. When I came too I was crying in pain but the doctor said We Got it. And that was that.