Is this a real thing?
Yes, there is such a thing as a fecal transplant. While it may sound gross or something that’s made up, it’s not. It’s actually used in medicine for very specific purposes. What are these? Who benefits from having a fecal transplant? How are they done?
Did you know that your stomach is home to millions of bacteria? Your digestive system depends on beneficial bacteria to absorb nutrients and digest food efficiently. Bacteria also help maintain the normal movement of food and stool through your gut. There are both “good” and “bad” bacteria inside your digestive tract, and they usually maintain a delicate balance. Sometimes, an imbalance occurs, and the “bad” bacteria outnumber the “good.” This can result from a loss of beneficial bacteria, an increase in potentially harmful ones, or a decline in the overall diversity of your microbiota, which leads to dysbiosis. The most common reason for this is antibiotics being used to treat an infection. In addition to getting rid of the infection, it can destroy your “good” bacteria too. Without the balance, the “bad” bacteria can take over. They produce toxins that make you sick. A fecal transplant can restore your gut’s healthy bacteria balance by putting stool full of healthy bacteria into your colon.
The idea of fecal transplants isn’t new. It began in ancient Chinese medicine more than 1,700 years ago. Back then, the procedure involved drinking a liquid suspension of another person’s feces. Obviously, not only gross but highly risky. Thankfully, today’s fecal transplants are sterile and safe. For the past few decades, there has been a growing body of research to support their use. Their benefit really came into light in 1958 when doctors tried the procedure as a last-ditch effort in four patients with life-threatening Clostridium difficile (C. diff) infection. While all four patients survived, fecal transplant failed to win mainstream acceptance because of a general revulsion to the thought. However, in 2013, a landmark study published in the New England Journal of Medicine showed that fecal transplant is superior to vancomycin (current gold standard) in treating C. diff. Another small-scale 2014 trial proved that 70% of the participants had no symptoms after one fecal transplant treatment, and the overall cure rate was 90% among those who underwent multiple treatments. Several larger studies soon confirmed these results.
Who does it benefit?
Fecal transplantation is also called bacteriotherapy and fecal microbiota transplantation (FMT). It’s primarily used in treating recurrent C. diff colitis, or C. difficile-associated disease (CDAD), which is a complication of antibiotic therapy. Symptoms often include diarrhea, abdominal cramping, and sometimes fever. Individuals who have the condition can’t function that well because of how sick they are. If you are over the age of 65 and/or have chronic illnesses, you may be at higher risk of more severe infection. On average, CDAD kills about 15,000 people each year. The 2011 data shows that C. diff caused over 500,000 infections, 29,000 deaths, and $4.8 billion in healthcare costs. Typically, the initial treatment involves an antibiotic that specifically targets the C. diff organism, such as metronidazole, vancomycin, and fidaxomicin. For roughly 30% of individuals, the infection returns within a few days or weeks after finishing the antibiotic course. Sometimes, the doctor may choose to treat this first recurrence with another round of antibiotic therapy. However, for those who continue to have recurrent episodes, fecal transplantation is an option. A fecal transplant often clears up the infection quickly and has an excellent success rate. According to a 2019 review, fecal transplant has been found to have a 70% to 93% cure rate in patients who have experienced repeated C. diff.
How are donors found?
For a person to receive a fecal transplant, there needs to be donor stool. There’s a strict process involved in screening individuals who are donors. They shouldn’t have had any antibiotic exposure in the past six months, be immunocompromised, have had any tattooing or body piercing in the past six months, have any history of drug use, have any history of high-risk sexual behavior, have any history of incarceration, have recently traveled to endemic areas, and have any chronic GI disorders (ex. inflammatory bowel disease). In addition, they’ll need to have several blood tests (ex. Hepatitis A, B, and C serologies, HIV, and rapid plasma reagin) and stool tests (ex. ova and parasites, C. difficile polymerase chain reaction, culture and sensitivity, and giardia antigen). It’s important to note that insurance companies might hold donors financially responsible for all testing.
Another option is getting frozen, screened poop from stool banks. Many places rely on stool from OpenBiome, which is a nonprofit stool bank. It provides frozen stool that has been rigorously screened and can be shipped to medical facilities for clinical use.
How is it done?
If you’re using a local donor, they’ll take a laxative the evening before the procedure. The next morning, they’ll collect their stool in a container obtained from the pharmacy and deliver it to the facility where the transplant will occur. The center will prepare the stool for transplant by mixing it with sterile water and filtering it repeatedly to remove the solids. The result is a brown liquid that contains good bacteria. Once prepared, it must be transplanted within six hours.
For the recipient, your doctor will provide you with specific instructions that you must follow before your procedure. Typically, you’ll need to stop any antibiotic therapy two days prior, follow a liquid diet and take an enema or laxative preparation the night before. Your doctor will instruct you regarding any prescription medication you take. On the day of your procedure, you’ll take loperamide to keep you from having diarrhea, helping you hold in the donated stool, so it’s more effective. Since sedatives are given via an intravenous (IV) catheter during the treatment, make sure a responsible adult accompanies you on the day of the procedure to take you home after it is finished.
The most common way a fecal transplant occurs is through a colonoscopy. The colonoscope is inserted into the anus and slowly advanced through the entire colon, where the stool sample is released as the scope is removed. It takes around 30 minutes. Once the procedure is finished, you will need to recover from the sedatives before going home, where you should rest for the remainder of the day.
Another approach involves injecting liquid feces via an enema. For this method, the stool sample is placed into the enema bag or bottle, then infused into the rectum, where it is held as long as possible. This may need to be done repeatedly over a few days to make sure enough of the “good” bacteria are left behind in the intestinal tract.
If, for some reason, you can’t have a colonoscopy or enema, the transplant may be done via an upper endoscopy. An endoscope is inserted into your mouth during this procedure, and air is used to open the esophagus, stomach, and intestine fully. Then, the stool is then placed into your small intestine. This takes approximately 15 to 20 minutes. Similar to a colonoscopy, you’ll receive some sedation via an IV.
Another option uses a feeding tube to infuse the stool sample directly into the intestine via a nasal tube placed directly into the intestine. This is typically reserved for patients who can’t tolerate other methods.
A newer technique that isn’t as widely used is a capsule that gets placed in your gut through a long tube that goes up your nose and down into your stomach. After the donated poop is screened and prepared, it’s frozen and placed inside tiny capsules. Typically, you’ll need to take 15 capsules over two days. However, you may be required to ingest as many as 40 capsules over several days. During this period, you’ll be monitored by your healthcare provider for any side effects.
After any of the procedures, you’ll be asked to hold your stool for at least two hours to prevent eliminating the new bacteria. When it comes to success rate, the best is the colonoscopy method. The least effective is the capsule approach. Most people experience relief of gastrointestinal symptoms within 48 hours after the procedure, but it can take up to three months for the gut bacteria to resemble the donor.
There are some possible side effects of fecal transplants. Sometimes, the antibiotics can cause diarrhea, a rash, and nausea. Also, the transplant can cause abdominal discomfort/cramping, constipation, bloating, nausea, diarrhea, belching or flatulence, and a reaction to the sedative. However, research shows the effects are not typically severe and usually go away with time.
If your symptoms recur within four weeks, the procedure is thought to have failed. For some, this can mean that they need a second fecal transplant. It’s important to note that there are no specific guidelines for optimal timing for a second round. A 2016 study identified several risk factors that might lead to fecal transplant failure, such as being female, previous hospitalization, and recent surgery before the transplant. Since taking antibiotics after a fecal transplant may cause complications, it’s important to tell your doctor about any current medications and antibiotics. Also, you should mention to your doctor if you’ve had a recent fecal transplant if you have an infection and need antibiotics.
A fecal transplant can be risky for certain individuals, so your healthcare provider may advise against the procedure. Things that can preclude you from it are having a recent bone marrow transplant, taking immunosuppressant medications, having cirrhosis of the liver, having HIV/AIDS, or undergoing treatment for cancer.
It’s vital to point out that fecal transplants should never be done at home. The risks are too dangerous and can include perforating your colon or damaging your rectum. Another major concern is that without proper screening, a donor could transmit serious and potentially lethal diseases. An example of how serious this is came from June 2019, when two immuno-compromised adults received investigational fecal transplants containing a strain of antibiotic-resistant E. coli. According to the Food and Drug Administration (FDA) investigation, both individuals received stool from the same donor, who wasn’t screened for disease-causing bacteria. In response, the FDA announced new standards requiring researchers in clinical trials to demonstrate proper screening procedures for donor stool. Per the FDA, fecal transplants are an “investigational new drug” and haven’t been approved for general use. The FDA does permit it to treat C. difficile infections that haven’t responded to standard treatments, provided that donors are thoroughly screened, and patients are thoroughly informed about the potential benefits and risks. This is why medical insurers typically only cover them as a treatment for recurrent, intractable C. diff.
One of the biggest questions is: How effective is fecal transplant for conditions other than C. diff? More and more evidence supports the idea that an unbalanced gut bacteria may play a role in many other health problems because gut health affects the body’s ability to absorb and use nutrients. Current research is looking at the impacts fecal transplants may have on ulcerative colitis (UC), Crohn’s disease, cirrhosis, multiple sclerosis, dementia, depression, obesity, food allergies, fibromyalgia, chronic fatigue syndrome, nonalcoholic fatty liver disease, hay fever, arthritis, asthma, eczema, diabetes, and diabetic neuropathy.
When it comes to ulcerative colitis, fecal transplants show a lot of promise as a potential treatment option. One reason is that the condition often results in an unhealthy mix of gut bacteria that makes it hard to fight off stomach infections. There is some evidence that donor “matching” can improve the chance of success. One study found that when people with UC received a fecal transplant that used stool from two donors mixed together, they saw improved symptoms and lower inflammation only a month later. In fact, 15% of patients went into remission. In addition, the study found that family members often make better donors than those chosen at random. However, a 2016 review found that success rates in trials ranged from 36.2% to 77.8%, which indicates that further research is definitely needed. For one thing, when it comes to inflammatory bowel diseases, scientists don’t know if the imbalance of bacteria is a consequence of the illness or if they play a role in its development.
Some scientists are worried that all the excitement about fecal transplants’ potential benefits could result in people overlooking other standard treatments that are effective for various conditions. Another concern is the long-term impacts of fecal transplant aren’t known. Even with these unknowns, researchers are looking ahead to the multiple possibilities. One concept being explored is the idea of “super-donors,” which refers to people whose gut bacteria is ideal for a fecal transplant, making them more desirable donors than others.
Another technique being looked at is autologous restoration of gastrointestinal flora (ARGF). In this process, patients at risk for the destruction of the normal intestine bacteria, like those who undergo stem cell transplants, provide a sample of their own stool, which is stored after being filtered and freeze-dried. If needed, it can be placed back into the person’s intestines. A 2018 study from Memorial Sloan-Kettering Cancer Center found that ARGF can restore gut bacteria that may be destroyed in patients undergoing a stem cell transplant.
When it comes to fecal transplants, the evidence is promising not only for C. diff but also for other conditions. While it’ll take time to know this for sure, until then, for those who genuinely need it, fecal transplants can make a huge difference!