Medical Policy

Colonic irrigation (also known as colonic lavage, hydrotherapy of the colon and colonics) is a procedure to wash out (or lavage) fecal material on walls of the large bowel. High-volume colonic irrigation involves the use of 35 or more liters of water, which is fed by gravity, to cleanse the colon. High-volume colonic irrigation has been proposed as an alternative to the traditional oral bowel preparations that are used to cleanse the colon prior to colonoscopy or other endoscopic procedures and as a treatment for constipation and bloating.

This document addresses the use of high-volume colonic irrigation and does not address other types of colonic irrigation which utilize smaller quantities of water, including, but not necessarily limited to, transanal and intraoperative (antegrade and retrograde) colonic irrigation.

Note: Please see the following related documents for additional information:

• CG-MED-95 Transanal Irrigation

Note: For a high-level overview of this document, please see “Summary for Members and Families” below.

 Investigational and Not Medically Necessary:

High-volume colonic irrigation is considered investigational and not medically necessary for all indications.

This document describes clinical studies and expert recommendations, and explains why high-volume colonic irrigation is not clinically appropriate. The following summary does not replace the medical necessity criteria or other information in this document. The summary may not contain all of the relevant criteria or information. This summary is not medical advice. Please check with your healthcare provider for any advice about your health.

Key Information

High-volume colonic irrigation is a procedure that uses large amounts of water, at least 35 liters, to wash stool out of the large intestine through the rectum. It has been promoted as an alternative to standard bowel preparation before a colonoscopy and as a treatment for constipation or bloating. Some people may find it more comfortable than drinking bowel-cleansing solutions. However, better studies are needed to know if high-volume colonic irrigation improves health or works as well as standard treatments. The procedure can cause side effects and may lead to serious complications in some cases.

What the Studies Show

During high-volume colonic irrigation, water is placed into the large intestine through a tube inserted into the rectum. The water and stool are then removed through a closed system. Some systems may add substances such as herbs, vitamins, probiotics, or enzymes to the water. The procedure has been marketed as a way to prepare for colonoscopy or to relieve constipation and bloating.

There is a limited amount of research evaluating high-volume colonic irrigation. One study in people with inflammatory bowel disease found that most participants had adequate bowel cleansing before colonoscopy and reported high satisfaction with the procedure. However, this study did not compare the procedure with standard bowel preparation methods. Better studies are needed to know if high-volume colonic irrigation improves health or works as well as accepted alternatives. Reported side effects include nausea, vomiting, dizziness, abdominal cramps, diarrhea, bloating, and soreness around the anus. Serious risks may include infection, electrolyte imbalances, water intoxication, and the possibility of a tear in the wall of the large intestine.

Is this clinically appropriate?

High-volume colonic irrigation is not clinically appropriate because it has not been proven to improve health. Current research is not sufficient to determine whether it is safe, effective, or provides better health outcomes for any use, including colonoscopy preparation, constipation, or bloating. Better studies are needed to know if high-volume colonic irrigation improves health or works as well as accepted alternatives.

Because the benefits have not been clearly proven and there are known risks, the possible harms may outweigh the uncertain benefits. Studies are also needed to better understand how often serious complications occur.

(Return to Description/Scope)

Summary

High-volume colonic irrigation involves the instillation of large volumes of water (at least 35 liters) via the rectum to wash out (or lavage) fecal material on walls of the colon (large intestine or large bowel). High-volume colonic irrigation has been investigated as a means to cleanse the colon prior to colonoscopy or other endoscopic procedure and as a treatment for constipation and bloating.

Currently there is insufficient scientific evidence published in peer-reviewed medical literature that permits reasonable conclusions concerning the safety, efficacy, or improved net health outcomes of high-volume colonic irrigation for any indication. Additionally, the early publications on colonic irrigation raised safety concerns including, but not limited to, rectal perforation, post procedure infection, water intoxication, electrolyte imbalances, microbiome disruption, chemical colitis, as well as toxin and bacterial absorption. Reasonable, well-designed studies are needed to provide quantitative estimates of the potential for adverse events when high-volume colonic irrigation is performed as well as comparative studies to evaluate the efficacy of this technique versus widely accepted alternatives.

Discussion

During a colonic irrigation procedure, water is instilled into the colon via a nozzle inserted into the rectum to cleanse (evacuate) the contents of the lower colon. The system is designed to allow evacuation of the contents of the colon during the procedure. The device consists of a container for fluid connected to the nozzle via tubing and includes a system which enables the flow, temperature, and pressure of water through the nozzle to be controlled. Because the method involves an enclosed system, the waste materials are removed without the unpleasant odors or discomfort usually associated with enemas. Sometime ingredients such as herbal extracts, vitamins, probiotics, or enzymes may be added to the water. The device may also include a console-type toilet and the fittings needed to connect to the water and sewer pipes. Additionally, the device may utilize electrical power to heat the water. Some devices consist of disposable nozzles and tubing while others employ components that need to be sterilized. The device does not include an enema kit (§ 876.5210; U.S. Food and Drug Administration [FDA], 1996).

Historically, colonic irrigation has been investigated as a treatment for various indications including, but not limited to, detoxifying the body, normalizing bowel function, managing symptoms associated with inflammatory bowel disease (IBD), promoting weight loss, managing menstrual irregularities, preventing colon cancer and fostering general well-being. More recently, high-volume colonic irrigation which uses large volumes (35 liters or more) of water to remove fecal matter from the large bowel, has been promoted as an alternative to traditional bowel preparation prior to colonoscopy and as a treatment for chronic constipation. This document addresses the use of high-volume colonic irrigation and does not provide guidance on the other types of colonic irrigation, which use smaller quantities of water, including but not necessarily limited to transanal, intraoperative (antegrade and retrograde) and colonic irrigation performed to promote wellness or detoxify the body.

The FDA classifies colonic irrigation systems as Class II or Class III devices. Class II colonic irrigation devices can legally only be marketed for medically indicated colon cleansing (such as before a radiologic endoscopic examination). Class III devices include colonic irrigation devices intended for other uses, including colon cleansing routinely for general well-being. No system has been approved by the FDA for "routine" colon cleansing to promote the general well-being of a patient (§ 876.5210; FDA, 1996).

Currently, at least one high-volume colonic irrigation system, the HyGIeaCare^® System (HyGIeaCare, Inc., Austin, TX), is commercially available in the United States. According to information on the manufacturer’s website, the HyGIeaCare^® System “is an FDA cleared prescription medical device, approved only for colon cleansing, when medically indicated, such as before radiologic or endoscopic examinations.” At the time of this review, two high-volume colonic irrigation procedures utilizing the HyGIeaCare Prep System were identified: the HygiPrep^® and the HygiRelief^® (HyGIeaCare System, 2020).

The HygiPrep is marketed as an alternative to the traditional oral purgative preparations given to individuals undergoing a colonoscopy. In preparation for the HygiPrep procedure, the high-volume colonic irrigation is scheduled to take place on the same day as but prior to the colonoscopy. On the day prior to the colonoscopy, the patient is asked to consume a clear diet, take a mile over the counter laxative, and get a good night’s rest. The patient is asked to arrive at the HyGIeaCare^® facility at the scheduled time, typically a few hours prior to the colonoscopy. The high-volume colonic irrigation procedure is generally completed within one hour. Once the HygiPrep is completed, the patient is free to go to their colonoscopy appointment. Proponents of the HygiPrep report the high-volume colonic irrigation lowers barriers to colonoscopy because it is a safe and effective means to obtain adequate visualization of the colon while eliminating the need and time for conventional oral bowel preparation prior to colonoscopy.

The HygiRelief^® is carried out at HyGIeaCare, Inc facilities and is marketed as a natural, medication -free and nonsurgical treatment to provide relief from bloating and constipation (described on the HyGIeaCare site as three or fewer bowel movements per week). Unlike the HygiPrep, bowel preparation is not required prior to the HygiRelief procedure (HyGIeaCare System, 2020).

The diagnostic accuracy and therapeutic safety of colonoscopy depends upon the quality of bowel cleansing which is sometimes perceived as the most unpleasant part of the procedure in individuals undergoing this examination. The ideal colonoscopy bowel prep should reliably and safely empty the colon of all fecal material allowing the optimal visualization of the entire colonic mucosa without causing significant shifts in fluids or electrolytes or great patient discomfort. Currently, there is a lack of evidence in the peer-reviewed scientific literature to permit conclusions about the net health outcomes of high-volume colonic irrigation for any indication. Information on the HyGIeaCare web site states “several studies, including a recently published randomized-control trial, have shown this method to be a safe alternative with a high percentage of adequate bowel preparation and increased patient satisfaction when compared to traditional oral purgatory preparations.” However, an examination of the peer-reviewed, published literature indexed in the PubMed database identified a single study exploring the use of high-volume colonic irrigation as an alternative to standard bowel prep for colonoscopy, other endoscopic procedures or as a treatment for constipation or bloating.

Gajera and colleagues (2022) reported the results of a retrospective clinical trial that evaluated the use of an FDA cleared, defecation-inducing high-volume colon irrigation (> 40 L) to prepare individuals with inflammatory bowel disease (IBD) for colonoscopy. Data were collected at four HyGIeaCare centers in the United States from September 2016 to March 2021. The study population consisted of 314 participants that underwent 343 bowel preparations (BPs). The BPs were prescribed by a total of 65 physicians and performed by 16 technicians and nurses. Study participants ranged from 20-85 years of age, 76% females and 24% males and 97% of the subjects were adequately prepared for their colonoscopy (n=309). Per post-procedure surveys and open-ended response text analyses, patient satisfaction with the BP was very high. Adverse events that occurred during and immediately after the high-volume gravity-fed colonic lavage with induced defecation BP procedures were documented by the center’s staff and included nausea, vomiting, dizziness, and abdominal cramping. No serious adverse events were reported. The authors concluded that the defecation-inducing high-volume colon irrigation BP for colonoscopy is safe, effective, and a favorable strategy for colonoscopy preparation in individuals with IBD.

High-volume colonic irrigation can cause minor side effects like nausea and abdominal cramping, but serious complications such as rectal or bowel perforation, electrolyte imbalance, infection are also possible. Rectal or bowel perforation caused by direct injury from the irrigation device or as a result of excessive hydrostatic pressure from colonic irrigation solution may tear the lower colon and require emergent medical repair (Choi, 2013; Handley, 2004; Tan, 1999). Flushing the large colon with large amounts of fluid can disrupt the balance of serum electrolytes such as potassium, sodium and chloride levels and lead to cardiac arrhythmias and seizures (Norlela, 2004). Electrolyte imbalances can be particularly dangerous for individuals with heart or kidney conditions. Istre (1982) reported an amebiasis outbreak at a Colorado chiropractic clinic that provided colonic irrigation therapy services. The outbreak resulted in at least 36 cases of infections and forced 6 individuals to undergo colectomy. The infections were traced to unsterilized colonic irrigation equipment heavily contaminated with fecal bacteria.

Although some, but not all known possible side-effects of colonic irrigation are discussed above, no peer-reviewed scientific literature was found that examined the safety of high-volume colonic irrigation when compared to traditional bowel preparation prior to colonoscopy for any indication. While no guidelines, recommendations or position statements from professional organizations or medical societies were identified that specifically addressed high-volume colonic irrigation, the National Center for Complementary and Integrative Health (NCCIH, 2019) issued the following caution with regards to the safety of colonic irrigations in general: “Colon cleansing procedures may have side effects, some of which can be serious. Harmful effects are more likely in people with a history of gastrointestinal disease, colon surgery, severe hemorrhoids, kidney disease, or heart disease.”

High-volume colonic irrigation involves the instillation of large volumes of water (at least 35 liters) via the rectum which are not retained and are almost immediately evacuated, along with colonic contents. High-volume colonic irrigation is being investigated as an alternative to traditional oral bowel preps prior to colonoscopy and as a treatment for constipation and bloating.

Colon cleansing: The ingestion of any number or combination of liquid or powdered laxative substances for the purpose of cleansing the colon of waste materials. Colon cleansing is distinct from but may be administered during a colonic irrigation.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services are Investigational and Not Medically Necessary:
For the following procedure code or when the code describes a procedure indicated in the Position Statement section as investigational and not medically necessary.

Peer Reviewed Publications:

1. Choi PW. Colorectal perforation by self-induced hydrostatic pressure: a report of two cases. J Emerg Med. 2013; 44(2):344-348.
2. Gajera A, South C, Cronley KM, et al. High-volume colonic lavage is a safe and preferred colonoscopy preparation for patients with inflammatory bowel disease. Crohns Colitis 360. 2022; 4(3):otac024.
3. Handley DV, Rieger NA, Rodda DJ. Rectal perforation from colonic irrigation administered by alternative practitioners. Med J Aust. 2004; 181(10):575-576.
4. Istre GR, Kreiss K, Hopkins RS, et al. An outbreak of amebiasis spread by colonic irrigation at a chiropractic clinic. N Engl J Med. 1982; 307(6):339-342.
5. Norlela S, Izham C, Khalid BA. Colonic irrigation-induced hyponatremia. Malays J Pathol. 2004; 26(2):117-1118.
6. Tan MP, Cheong DM. Life-threatening perineal gangrene from rectal perforation following colonic hydrotherapy: a case report. Ann Acad Med Singap. 1999; 28(4):583-585.

Government Agency, Medical Society, and Other Authoritative Publications:

1. Centers for Disease Control (CDC). Amebiasis associated with colonic irrigation--Colorado. MMWR Morb Mortal Wkly Rep. 1981; 30(9):101-102.
2. National Institutes of Health. National Center for Complementary and Integrative Health. “Detoxes” and “cleanses: what you need to know”. Last updated March, 2025. Available at: https://www.nccih.nih.gov/health/detoxes-and-cleanses-what-you-need-to-know. Accessed on August 13, 2026.
3. U.S. FDA Center for Devices and Radiological Health (CDRH). Gastroenterology/Urology Devices - therapeutic devices: colonic irrigation system (Sec. 876.5220) (1996). Last amended August 6, 2026. Available at: https://www.ecfr.gov/current/title-21/chapter-I/subchapter-H/part-876/subpart-F/section-876.5220. Accessed on August 12, 2026.

1.  American Cancer Society/ How to use integrative (holistic) therapy safely. Last updated July 11, 2025. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/treatment-types/complementary-and-integrative-medicine/complementary-and-alternative-methods-and-cancer.html. Accessed on August 13, 2026.

Colonic Irrigation

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Applicable to Commercial HMO members in California: When a medical policy states a procedure or treatment is investigational, PMGs should not approve or deny the request. Instead, please fax the request to Anthem Blue Cross Grievance and Appeals at fax # 818-234-2767 or 818-234-3824. For questions, call G&A at 1-800-365-0609 and ask to speak with the Investigational Review Nurse.

Federal and State law, as well as contract language, including definitions and specific contract provisions/exclusions, take precedence over Medical Policy and must be considered first in determining eligibility for coverage. The member’s contract benefits in effect on the date that services are rendered must be used. Medical Policy, which addresses medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Medical Policy periodically.

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