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Persistent Hiccups Because of Water Intoxication by Colonic Irrigation With Tap Water

van Weelden, Marlon MD1; Edelenbos, Esther MD1; de Meij, Tim MD, PhD1

doi: 10.14309/crj.0000000000000148

ABSTRACT Hyponatremia by colonic irrigation with water is a rare complication, especially in children. We describe a child with chronic constipation who was admitted because of persistent hiccups provoked by severe hyponatremia by water intoxication due to colonic irrigation with tap water. Awareness of complications of colonic irrigation may be crucial for health care providers and parents to rapidly recognize a serious underlying problem.

1Department of Pediatric Gastroenterology, VU University Medical Center, Amsterdam, the Netherlands

Correspondence: Marlon van Weelden, Jan Tooropstraat 661, 1061 AE, Amsterdam, the Netherlands +31648609514 (

Received February 24, 2019

Accepted May 13, 2019

Online date: August 8, 2019

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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Transanal irrigation was first described as a therapy of fecal incontinence in children with spina bifida by Shandling and Gilmour in 1987.1 Nowadays, colonic irrigation is a well-tolerated, noninvasive, effective treatment in both children and adults with organic and functional causes of constipation.2–4 Consequently, over the past few years, colon irrigation is increasingly being used in constipated children in home settings. Hyponatremia by colonic irrigation is a rarely described complication. To recognize the symptoms of hyponatremia may be challenging because the symptoms are nonspecific; however, it is crucial to prevent severe neurological complications including cerebral edema.

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A 12-year-old girl with a history of mitochondriopathy (most likely POLG1 mutation, which was not further investigated at the request of the parents), neurodevelopment delay, epilepsy, and daily colonic irrigation with 1.5 L of tap water because of chronic constipation presented at our hospital for evaluation of persistent hiccups. She had several hiccups per minute for 1 day. Since a few days, only 1.0 L of the used 1.5 L of water was evacuated from the rectum with the stools. We saw an alert girl with hiccups with no other abnormalities except her underlying psychomotor retardation. Laboratory investigation showed an isolated hyponatremia (120 mmol/L). Serum osmolality was consequently decreased (246 mOsmol/kg). Urine sodium level was <20 mmol/L. Our patient was diagnosed with hiccups by hyponatremia caused by water intoxication due to colonic irrigation with tap water. She was treated with sodium suppletion and fluid restriction. Sodium levels normalized, and hiccups disappeared within 1 day. Colonic irrigation was switched to saline.

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Differential diagnosis of persistent hiccups includes vagus/phrenic nerve stimulation and cardiovascular, toxic-metabolic, and psychogenic causes. Metabolic changes may cause suppression of the central nervous system on peripheral nerves, inducing hiccups. Several case reports have described the occurrence of hyponatremia by colonic irrigation with tap water.5,6 Hiccups by hyponatremia have been described only in adults.7–9 To our knowledge, this is the first report of a patient with hiccups by hyponatremia, resulting from colonic irrigation with tap water. Hyponatremia can lead to serious neurological complications, including cerebral edema. Children may be especially vulnerable because of their limited total body water space. Hiccups may be the earliest or only symptom of severe hyponatremia and should always be considered in the differential diagnosis of patients using colonic irrigation with tap water. The volume of water drained in our patient was more than the volume of water that was evacuated from the rectum after. Colonic irrigations are generally performed with a volume of 10 to 20 mL/kg. Our patient received 1.5 L of water to irrigate with the weight of approximately 50 kg. In conclusion, education is important for the use of colonic irrigation, especially in home settings.

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Author contributions: All authors wrote the manuscript and are the article guarantors.

Financial disclosure: None to report.

Informed consent was obtained for this case report.

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1. Shandling B, Gilmour RF. The enema continence catheter in spina bifida: Successful bowel management. J Pediatr Surg. 1987;22(3):271–3.
2. Jørgensen CS, Kamperis K, Modin L, Rittig CS, Rittig S. Transanal irrigation is effective in functional fecal incontinence. Eur J Pedriatr. 2017;176(6):731–6.
3. Koppen IJ, Kuizenga-Wessel S, Voogt HW, Voskeuil ME, Benninga MA. Transanal irrigation in the treatment of children with intractable functional constipation. J Pediatr Gastroenterol Nutr. 2017;64(2):225–9.
4. Mosiello G, Marshall D, Rolle U, et al. Consensus review of best practice of transanal irrigation in children. J Pediatr Gastroenterol Nutr. 2017;64(3):343–52.
5. Jacob J, Tully SB, Chapman B. Hyponatremia and perforation of the bowel following a series of water enemas: A case report in a 14-month-old infant. Clin Pediatr (Phila). 1976;15(9):776–8.
6. Blanc P, Carbajal R, Paupe A, Lenclen R, Couderc S, Olivier-Martin M. Water intoxication following preparation for barium enema. Arch Pediatr. 1995;2(9):871–3. [French.]
7. George J, Thomas K, Jeyaseelan L, Peter JV, Cherian AM. Hyponatraemia and hiccups. Natl Med J India. 1996;9(3):107–9.
8. Ramirez FC, Graham DY. Hiccups, compulsive water drinking, and hyponatremia. Ann Intern Med. 1993;118(8):649.
9. Jones JS, Lloyd T, Cannon L. Persistent hiccups as an unusual manifestation of hyponatremia. J Emerg Med. 1987;5(4):283–7.
© 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.