Enema of Traditional Chinese Medicine for Patients with Severe Acute Pancreatitis

Summary

An enema is a type of traditional Chinese medicine (TCM) therapy used to treat severe acute pancreatitis (SAP). The therapy involves instilling a TCM liquid into the rectum and colon through the anus to keep the liquid in the intestine, absorbing through the intestinal mucosa. This study aims to standardize the enema procedure for SAP patients.

Abstract

Severe acute pancreatitis (SAP) is characterized by high mortality rates, numerous complications, and extreme difficulties in treatment. A traditional Chinese medicine (TCM) enema has been widely utilized in clinical and experimental studies of SAP. It has been demonstrated to have beneficial effects in protecting pancreatic function and delaying disease progression. The procedure of TCM enema is to perfuse the Chinese medicinal liquid of raw rhubarb (Rheum officinale Baill. DaHuang) from the anus into the rectum and colon. Basic steps of the procedure include boiling the herbal solution in advance, using a disposable enema kit to assist patients in taking a left lying position, raising the patient's hip 10 cm, and carefully inserting the enema 30-35 cm into the anus, with a drip speed of 60-80 drops/min. The medicine liquid temperature should be equivalent to the patient's body temperature, typically between 37-39 °C. The end of the enema operation should be slow, and Tui na (massage therapy) should be administered before extubation. The medication liquid should be kept in the rectum for more than 1 h. After issuing an enema, it is essential to observe the patient's feces and abdomen, and to evaluate the remission of abdominal signs and symptoms.

Introduction

Acute pancreatitis (AP) is an acute abdominal disease, characterized by a local pancreatic inflammatory response from an abnormal activation of pancreatic enzymes that have a digestive effect on the pancreas and surrounding organs¹. As one of the most prevalent gastrointestinal reasons for hospitalization in the United States, acute pancreatitis requires increasing attention as it continues to increase worldwide^2,3. In the past decade, the understanding of the pathophysiological mechanisms of acute pancreatitis has made significant strides^4,5,6. About 5%-10% of cases of acute pancreatitis are associated with severe organ dysfunction; this type of pancreatitis is defined as severe acute pancreatitis (SAP)⁷. Early Western medical treatment of AP generally consists of fluid therapy, analgesia, nutritional support, and treatment for the cause and early complications. However, Western medical treatment still lacks specific drugs for AP at this stage^8,9,10.

In traditional Chinese medicine (TCM), AP is referred to as "abdominal pain", "Pi Xin Tong", and "pancreatic fever". TCM enema therapy is one of the most used treatments in Chinese medicine, dating back to the honey decoction method from Zhang Zhong Jing's "treatise on cold pathogenic diseases" in the Han Dynasty¹¹. Its clinical efficacy is documented for the treatment of ulcerative colitis¹², hyperuricaemia¹³, acute radiation proctitis¹⁴, acute kidney injury¹⁵, and SARS-CoV-2 in the intestinal tract¹⁶.

In recent years, an enema with TCM (rhubarb^17,18, mirabilite¹⁹, and compound preparations such as Qingyi decoction²⁰ and Dachengqi decoction²¹) has been widely utilized in clinical and experimental studies of SAP. It has been shown to protect pancreatic function, reduce abdominal pain and abdominal distension, and delay disease progression^22,23. The 2021 Chinese guidelines for the diagnosis and treatment of AP include TCM enema²⁴. However, it is unclear how the TCM enema should be administered to SAP patients. Therefore, we present a protocol to perform the TCM enema, providing a potent method for investigating the components and mechanisms of ethnic drugs in the treatment of SAP patients²⁵.

Protocol

The clinical protocol has been approved by the Administrative Committee of Department of Critical Care Medicine, Hospital of Chengdu University of Traditional Chinese Medicine (Record number: KY20221005). Experimental procedures were carried out in accordance with the guidelines of Hospital of Chengdu University of Traditional Chinese Medicine. The consent of the patients, who have signed an informed consent form, is required for the operation. The operator should understand the anatomy of the rectum before administering the enema and look at the anatomical annotations (see Figure 3).

1. Pre-therapy preparation of the operator

1. Include patients with principal symptoms (i.e., persistent epigastric pain).
2. Exclude patients with the following conditions: gastrointestinal bleeding, pregnancy, severe cardiovascular disease, arteriovenous tumor, hemiplegia, stroke, cardiopulmonary-cerebral insufficiency, severe colon ulcer or infarction, hernia, abdominal surgery, patients with intestinal adhesions, ileocectomy, megacolon disease and bleeding or perforation, patients with intestinal surgery, dialysis, patients with instinctive hypertension, catatonic heart disease, or severe hemorrhoids.
3. Exclude patients with a breakage of the perianal skin and a history of allergy to rhubarb.
4. Ensure that patients have no psychiatric disorders and can actively cooperate with the treatment.

2. Pre-therapy preparation of the patients

1. Have the patient eliminate both stool and urine before the operation.
2. Inform the patients that is it normal to experience localized sensations such as swelling, fullness, and mild pain.
3. Have patients promptly notify if defecation occurs or if there is discomfort.
   ​NOTE: The enema solution should be retained for more than 1 h, as the long retention time facilitates drug absorption²⁶.

3. Preparation of the decocted medicinal liquid

NOTE: The Hospital of Chengdu University of TCM supplied the raw rhubarb²⁷ (Rheum officinale Baill. DaHuang) (Figure 1).

1. Add 30 g of raw rhubarb and 200 mL of water to the automatic decoction and packaging machine.
2. Boil, and then simmer for 5 min.
3. Filter with a non-woven filter package (24 mm x 30 mm).
4. Remove residue with the non-woven filter package and cool down the remaining liquid to 37-39 °C.

4. Operational procedure

1. Check the patient's basic information (name, age, hospital number), verify the patient's condition, and re-evaluate them. Explain the process and advantages of an enema to the patient, making sure that they can fully understand and relax during it.
2. Regulate the room temperature (18-28 °C).
3. Prepare all necessary items (Figure 2 and Table of Materials). Check the expiration dates and bring them to the bedside.
4. Close all doors and windows. Ensure that the patients are not unnecessarily exposed and are kept warm.
5. Wash and dry hands, put on disposable gloves, and measure the temperature of the enema liquid using a thermometer beside the bed.
6. Assist the patient in assuming the left lateral decubitus position (if necessary, choose the right lateral decubitus position based on the condition). Fully expose the anus, place the center of the treatment sheet under the buttocks, and use a pillow to elevate the buttocks by 10 cm (Figure 3).
7. Lubricate the front end of the anal canal with paraffin oil, drain the paraffin oil from the anus, and expose the anus.
8. Adjust the temperature of the liquid medication to be equivalent to the patient's body temperature (37-39 °C) at a drip rate of 60-80 drops per minute, ensuring that the liquid level does not exceed 35 cm from the anus.
9. Close the stopper clip (part of the disposable enema kit) and pour the liquid into the hanging bag (part of the disposable enema kit).
10. Instruct the patient to open their mouth to breathe when inserting the anal canal, to relax the anus and facilitate the smooth insertion of the anal canal.
11. Insert the anus canal 30-35 cm²⁸ with the plastic hose (part of the disposable enema kit), open the stopper clip, and slowly drip the liquid (the dripping rate depends on the patient's condition) for 15 to 20 min.
    NOTE: If the plastic hose is blocked, close the stopper clip immediately and squeeze the pressurized bladder (part of the disposable enema kit) to unblock it.
12. During the infusion, constantly monitor and inquire about the patient's tolerance. Adjust the infusion rate in the event of discomfort or convenience and discontinue the infusion if necessary.
13. Perform general Tui na (place fingertips on the perianal skin to gently knead back and forth in a circular motion) to relax the muscles around the anus, before extubation of the plastic hose (Figure 2A)²⁹.
14. After administering the medication, clamp and remove the plastic hose from the anal canal.
    NOTE: The dosage for Chinese herbal enema should not exceed 200 mL.
15. Assist the patient in drying the perianal skin by gently rubbing the anus with gauze. Help the patient assume a comfortable lying position and elevate the buttocks.
    ​NOTE: If the patient has a sluggish pulse, a pale face, cold perspiration, severe abdominal pain, and palpitation, stop the operation immediately and contact a doctor.

5. Post-operation care

1. Have the patient lay in the left lateral position if they are still comfortable.
2. Have the patient rest. Advise them to use clean bedsheets, keep the anus dry and clean, and change the bedsheets promptly after fluid flows.
3. Observe fluid flow from the anus after the enema. Observethe shape, color, volume, and smell of the stool, to determine the success of the enema.
4. Advise the patient not to use excessive force to relieve stools, and inform healthcare staff promptly of any constipation.
5. Observe the patient's symptoms, temperature, blood pressure, pulse rate, heart rate, and respiration.

Results

In this study, the patient was admitted because of repeated epigastric pain. According to the diagnostic criteria³⁰, the patient was diagnosed with SAP. After the patient was treated with this protocol, there was a noted therapeutic effect³¹.

Patient A, a female, 84 years old, was diagnosed for the first time on May 2, 2019. The patient complained of repeated epigastric distension and pain. The clinical tests showed that the serum amylase was 509...

Discussion

AP is an inflammatory disease that can progress to SAP. According to numerous studies, SAP is a devastating disease linked with mortality ranging from less than 10% to as high as 85%, albeit with decreasing mortality in the recent decade³³. SAP seriously impacts patients' quality of life, and can even lead to death if not treated promptly and effectively. Aggressive and effective early treatment is of clinical importance³⁴.

Chinese herbal ene...

Materials

Name	Company	Catalog Number	Comments
Automatic decoction machine packaging machine	Taizhou Guo pin Le Ji Machinery Co., Ltd	GPJ13(1+1)
Care turning pillows	Hengshui Binhu New Area Fubon Medical Equipment Factory	20220902R
Disposable enema device	Yangzhou Yuankang Medical Equipment Co., Ltd.	20220502B
Disposable gloves	Jiangxi Almei Medical Equipment Co., Ltd.	AEM/ST-AZ
Disposable medical kit	Zhende Medical Supplies Co., Ltd.	20211220
Disposable treatment sheet	Xinxiang Huakang Eisai Co., Ltd	HK-38
Medical gauzepad	Xinxiang Huakang Eisai Co., Ltd	HK-02B
Medical nursing pad	Hefei Mattel Care Products Co., Ltd	CND502
Non-woven Filter Package	Chengdu New Medical and Health Products Factory	20192183#(C)
Paraffin oil	Shandong Lierkang Medical Technology Co., Ltd.	180801
Raw rhubarb	Sichuan Guoqiang traditional Chinese Medicine  Co., Ltd	21120104
Thermometer	Shenzhen Chenzhou Technology Co., Ltd.	TP300