Case Reports in Gastrointestinal Medicine

Case Reports in Gastrointestinal Medicine / 2017 / Article

Case Report | Open Access

Volume 2017 |Article ID 6432063 | 6 pages | https://doi.org/10.1155/2017/6432063

Hydrogen Peroxide Induced Colitis: A Case Report and Literature Review

Academic Editor: Tetsuo Hirata
Received09 Oct 2017
Accepted04 Dec 2017
Published25 Dec 2017

Abstract

Constipation is a common condition. Hydrogen peroxide enemas have rarely been reported as a home remedy for constipation in the pediatric age group. We present a case report and literature review of hydrogen peroxide induced colitis in pediatric siblings, aged 2 years and 9 years. The siblings presented with vomiting and bloody diarrhea an hour following the enema. Physical exam, vital signs, blood, and electrolyte counts were normal, but CT scans showed mucosal thickening of the rectum and colon. Their symptoms resolved after oral intake was curtailed and fluids were replaced intravenously. We discuss existing reports of complications from hydrogen peroxide enemas. Patients may present with abdominal pain and bloody diarrhea. Onset of symptoms varied from minutes to a day and bowel ulceration with necrosis and perforation has occurred, although fatality is rare. Diagnostic tests included computed tomography (CT) scan, sigmoidoscopy, or biopsy. Recovery period ranged from 3 days to 8 months. Public education regarding the dangers of hydrogen peroxide enemas is needed.

1. Introduction

Constipation is a common problem, reported in up to 30% of children. Home treatment for constipation includes eating foods high in fiber such as vegetables, citrus fruits, beans, and whole grains. A healthcare provider should be consulted before giving a laxative or enema to children. Internet searches for homemade remedies to treat constipation deliver hydrogen peroxide enema among the results. Hydrogen peroxide has been known to cause colitis and, in a few cases, bowel perforation. The earliest use of hydrogen peroxide enema in the pediatric population is documented by Olim and Ciuti to treat meconium ileus in the newborn [1].

Herein we present an unusual case of two siblings, aged 2 years and 9 years, presenting with bloody diarrhea and vomiting due to chemical colitis following hydrogen peroxide enema. We also present a systematic review of prior such cases. Few such cases have been reported in the pediatric population.

2. Case Presentation

Two siblings, a 2-year-old male and a 9-year-old female, had been constipated for 2 days. Patients did not have a family history of gastrointestinal issues and past medical history was unremarkable. The mother of the patients was providing both children with a regular but meat-free soy-based diet of her own volition. However, the children had rock-hard stools that could not be passed. Both patients were not given any prior conventional or homemade remedies. However, following an Internet search, both patients were then given an enema of hydrogen peroxide mixed with warm water. Concentration of hydrogen peroxide used is unknown. Following the enema, the patients passed stools but, an hour later, started vomiting and had bloody diarrhea.

Upon admission, vital signs were normal. Both patients had soft abdomens on exam, which were nontender to deep palpation, nondistended, and no guarding was noted. Physical exam did not raise concerns for perforations and the patients denied abdominal pain. Complete blood count and metabolic panel for both patients were within normal limits.

Abdominal CT for the patient of age 2 years showed mucosal thickening of the rectum and sigmoid colon with no free air. The patient aged 9 years had a more extensive mucosal thickening of the rectum, sigmoid, and descending colon but showed no perforation or free fluid. Both patients were admitted to the pediatric intensive care unit, had their oral intake withheld, and were given IV fluids. They showed clinical improvement the same day and were then transferred to the pediatric ward. Both patients were discharged 24 hours later with resolution of emesis and bloody stool. They were prescribed polyethylene glycol laxative, 17 grams, daily for constipation.

3. Discussion

We found 21 published cases related to hydrogen peroxide enema. Prior cases show the patient population as mostly older adults with constipation from secondary causes. To our knowledge, this is the first case of colitis due to hydrogen peroxide enema in siblings in the pediatric age group. The most recent case report was published in 2016 [16]. Cases related to oral ingestion of hydrogen peroxide as well as those associated with contamination during endoscopic examinations were excluded.

In 11 of the 21 cases, enema was self-administered; in the rest, enema was administered under physician supervision. The enema was administered to treat constipation, except for one case where the patient used it to treat prostate cancer. The enema concentrations varied and are listed in Table 1. Following the enema, patients were able to relieve their constipation but then presented with symptoms of abdominal pain/tenderness, bloody diarrhea, fever, tenesmus, leukocytosis, and/or tachycardia [17]. Endoscopy findings included mucosal friability, exudates, ulceration, necrosis, and/or perforation of the distal colon or rectum (Table 1) [17]. The onset of bloody diarrhea after administration of hydrogen peroxide enema varied from a few minutes to an entire day following the enema. Diagnostic tests varied with some combination of CT scan (4 cases), sigmoidoscopy (11 cases), or biopsy (4 cases). In our case, diagnosis was made solely using abdominal CT scan and patient history, without relying on additional sigmoidoscopy and biopsy findings because the temporal relationship of presenting symptoms following the enema favored the diagnosis of hydrogen peroxide induced colitis.


Author and yearPatient agePresenting historyComplicationsIatrogenicConcentration usedSymptom onsetTreatment/recovery period

Pumphrey  
(1951) [2]
50 yearsPeptic ulcer. Constipation 6 d priorAbdominal soreness, severe tenesmus, bloody mucus. Fever 103 F. Bowel mucosa covered with gray tenacious membrane, ulcerated, purulent exudate up to 24 cm from dentate lineYes2 : 1 hydrogen peroxide & waterUnknownGranulation tissue cauterized with silver nitrate. Recovery: 8 m

Pumphrey  
(1951) [2]
76 yearsChronic constipationDeveloped bloody mucus stools every 30–60 mins. Ulcerative proctosigmoiditis up to 24 cmNo (self)Full strength hydrogen peroxide30 mins1 gm sulfasalazine qid, rectal instillations of warm oil, 1 teaspoon of psyllium seed oral bid. Recovery: 3 w

Olim and Ciuti  
(1954) [1]
2 daysMeconium ileus due to pancreatic cystic fibrosisNone: meconium evacuatedYes1 : 3 3% hydrogen peroxide & water, via enterotomy

Ludington et al.
(1958) [3]
62 yearsPeptic ulcerAbd pain, rebound tenderness, left lower quadrant mild rigidity, decreased sensation on right side. Fever 103 F
2 seromuscular tears along mesenteric borders of sigmoid and transverse colon
Yes125 cc hydrogen peroxide in a liter of warm water, retained for 15 minsWithin hoursLaparotomy for seromuscular tears, gangrenous mucosa 4 cm dia. excised and repaired. Recovery: uneventful

Sheehan and Brynjolfsson  
(1960) [4]
41 yearsDuodenal ulcer, constipationSevere abd pain, rectal bleeding, vomiting, lost 500 ml of blood. Administered plasma. Died due to hemolytic reaction of unknown causes, followed by anuria, uremia, hemoglobinuric nephrosisNoUnknownImmediatePlasma for blood loss. Died due to following complications

Meyer et al.
(1981) [5]
22 yearsConstipationSmall bloody bowel movements every half hour with tenesmus and lower abd pain. Friable necrotic mucosa to 15 cm. Rectal mucosa improved but erythematous post 5 dNo10 ml 3% hydrogen peroxide + 30 ml water30 minsParenteral fluids, antibiotics, and rectal steroids. Recovery: mucosa normal at 10 d, asymptomatic at 1 m

Meyer et al.
(1981) [5]
47 yearsConstipationLower abd cramps, tenesmus, rectal bleeding over 24 hours. Diffuse, granular, friable mucosa and discrete ulcerations w yellow/green pseudomembrane. Focal acute ulcerations with edema and congestion of lamina propriaNoEnema of methylene blue dye + 1 oz (29 ml) peroxide in 500 ml water5 mins100 units ACTH over 8 hrs and then 30 mg prednisone for 2 wks. Recovery: no bleeding at 3 d, normal mucosa at 21 d

Meyer et al.
(1981) [5]
28 yearsConstipationOnset of severe abd cramps, loose bloody bowel movements. Fever 102 F, BP 150/90, pulse 110, RR 14. Diffuse ulcerations at 10 cm; congestion and edema in lamina propriaNoEnema of 150 ml 3% hydrogen peroxide and 60 ml food coloringFew minutes laterParenteral ACTH 100 units for 5 days, prednisone 30 mg daily. Recovery: 7 d, asymptomatic at 5 w

Bollen et al.
(1998) [6]
13 yearsChronic constipation after being sexually abusedAbd pain, rectal bleeding, no defecation. Hemorrhagic mucosal ulcerations from rectum to splenic angle. 48 hrs, sclerotic lamina propria. Mucosal glands focally destroyed, ischemia, microabscesses with polymorphonuclear leukocytesYes1 : 1 water & 10% hydrogen peroxide1 hrNo oral feeding for 48 hrs. Gradual complete recovery

Gan and Price  
(2003) [7]
67 yearsType 2 diabetes, prostate cancerProfuse diarrhea, initially nonbloody. Later, bloody tenesmus, urgency, soft and nontender abdomen. Normal rectal examination, other than a diffusely hardened prostate. Friable, inflamed mucosa in rectum, several white patches in inflammation area extending to 15 cm. No fibrosis, scarringNo (self)100 ml to 200 ml 3.5% hydrogen peroxide enema24 hrsRecovery: 10 d

Kirrane and Hoffman  
(2007) [8]
57 yearsAbdominal pain, rectal bleeding, tachycardiaLightheadedness, general weakness, abdominal pain. 12 hours later, multiple episodes of rectal bleeding. Tachycardia (heart rate 110 bpm). Distended abd, discomfort to palpation, no focal tenderness. Distended large bowel, thickened sigmoid colon consistent with colitis. No free air or gas embolizationNo30 ml 35% hydrogen peroxide + 750 ml waterWithin minutes; bleeding post 12 hrsRecovery: 3 d
Treated with intravenous fluids and oral simethicone

Almalouf et al.
(2008) [9]
19 years2 week abdominal pain from chronic cholecystitis, constipation following hydrocodone administrationPost 1 hr, abd pain, rectal bleeding. Acute abd, friable mucosa, leukocytosis, free retroperitoneal airYesSoap suds with hydrogen peroxide (500 ml, unknown conc)1 hourCeftriaxone, metronidazole. NPO 3 d until white blood cell counts within normal range. Recovery: 7 d

Desai and Orledge  
(2010) [10]
43 yearsLeft-sided abdominal pain, hematocheziaHematochezia every 30 mins, bowel wall thickening from rectum to distal one-third of transverse colonNoCommercial sodium phosphate/sodium biphosphate + hydrogen peroxideUnknownRecovery: 1 d

Kibria et al.
(2010) [11]
61 yearsConstipation unresponsive to milk of magnesiaAbd pain, bloody stools 1 hr later. Left lower quadrant tenderness. Rectosigmoid wall thickening, inflammation
Friable mucosa, discrete ulcerations & yellow/green pseudomembranes up to 40 cm from anus. Focal acute ulcerations, congestion of lamina propria
YesEnema with 90 ml each of hydrogen peroxide, sodium phosphate, and docusate sodium1 hrParenteral fluids, levofloxacin, and metronidazole. Recovery: 3 m

Volonte et al.
(2010) [12]
31 yearsSevere constipation following spinal trauma. 4000 ml/wk glycerol enema for defecationSevere abdominal pain soon after enema. 3 hr later CT showed extensive gas in portal vein. Resolved 48 hr laterYes700 cc hypertonic solution of 5% glycerin and 300 cc of 3% hydrogen peroxide solutionWithin hoursRecovery: 3 h

Lim et al.
(2011) [13]
49 yearsAbdominal painLower abdominal pain with bloody stoolsNoUnknown2 hoursNPO, IV fluids, antibiotics. Recovery: 5 d

Love et al.
(2012) [14]
59 yearsHypertension, coronary artery disease, diabetes, chronic kidney disease, constipationRectal bleeding, fecal incontinence over 12 hrs. Soft abd with diffuse tenderness on left lateral side. Rectal exam, presacral thickening, diminished anal tone. Colitis extending to 35 cm, edema & hemorrhage in lamina propria with “bubbly” appearance of goblet cellsNo120 ml hydrogen peroxide (1 : 1 3% hydrogen peroxide & water)Minutes afterAntibiotic and mesalamine enema. Recovery: 2 d

Taş et al.  
(2011) [15]
27 yearsConstipation over 2 yrsPost 2 hrs, abd pain, bloody diarrhea. Mild lower quadrant abd tenderness, painful digital rectal exam. Friable, granular ulcerated rectal mucosa. Rectal histopath exam, mucosal congestion, hemorrhage, necrosis, lymphatic ductal ectasiaNo200 ml 3% hydrogen peroxide2 hoursEnema with budesonide (2 mg). Recovery: 3 d

Recovery period ranged from 3 days to 8 months, with mostly uneventful gradual recovery. Recommended treatment included bowel rest, fluid resuscitation, and broad spectrum antibiotics, NSAIDs, or corticosteroids [17]. Depending on the extent of injury, most patients recovered after conservative medical therapy. However, serious consequences included death due to idiopathic hemolytic reaction following plasma transfusion to correct blood loss [4], portal vein embolism [12], and colonic rupture [3]. A summary comparing and contrasting diagnostic tests findings, medications prescribed, and complications of hydrogen peroxide induced colitis are documented in Table 1.

Hydrogen peroxide is available over the counter in concentrations of 3% and a “food grade” variety of 35%. Although it has a warning label stating “For external use only,” a study by the National Survey of Consumers and Health Professionals found that only 7% of consumers read usage warnings. Hence, public education on the dangers of hydrogen peroxide enema may be needed. It may be effective since patients tend to follow the advice of a competent physician over information obtained from the Internet [18]. Hydrogen peroxide has also been used for other indications like enlarged prostate and cancer of prostate [7]. Therefore, patients with unexplained colitis or proctitis may be queried about use of hydrogen peroxide enema.

Finally, the siblings followed a meat-free soy-based diet, and although soy protein has been known to be an allergen, we did not find an association between soy protein and constipation.

Conflicts of Interest

The authors declare that there are no conflicts of interest regarding the publication of this article.

Acknowledgments

The authors wish to acknowledge the contribution of the Texas Tech University Health Sciences Center Clinical Research Institute for their assistance with this research. Funding for article processing charges is provided by Texas Tech University Health Sciences Center Department of Internal Medicine.

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Copyright © 2017 Dushyant Pawar et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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