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Thursday, February 21, 2013

How to perform a fecal transplant--why make this so very difficult?

Fecal transplant, thanks to the recent article in the New England Journal of Medicine out of the Netherlands, has made it to the front page, the big time. In my inbox today was a link to a how-to article from medscape from a doctor from Eastern Virginia Medical School who apparently does the occasional fecal transplant for recurrent Clostridium difficile colitis.

In this article, the author says that one must do $500 worth of testing on the donor, then make up a particle free stool slurry of stool and non-bacteriostatic saline under a hood (due to the biohazard aspects of making poop soup) filter it and instill the mixture via a colonoscope to the patient who has taken 3 gallons of polyethylene glycol solution and preferably had only clear liquids for 2 days. He says that the procedure should only be done for patients who have had Clostridium difficile for 3 months which has not responded to antibiotic therapy.

There is no evidence to suggest that giving donor feces by colonoscopy is any better than giving it by low volume enema, at home, or by nasogastric tube. Colonoscopy carries significant risks: anesthesia is risky and colonoscopes can cause perforation and bleeding. Colonoscopies are expensive. The recent article in the New England Journal used a naso-duodenal tube, not a colonoscope.

There is reasonable evidence that fecal transplant is effective for treatment of ulcerative colitis, an autoimmune disease of the colon that causes chronic disability, colon cancer and internal bleeding. Acute Clostridium difficile claims many lives, and there is abundant experience of treating it with fecal transplant. Limiting this therapy to chronic cases seems a bit excessively restrictive.

The author of the medscape article notes that some of the patients in the recent trial of fecal microbiota transplantation developed new diseases, some of them autoimmune, which might have been related to the transplants. It seems unlikely, but I would also wonder whether some of the patients found that more problems than just their Clostridium difficile were resolved. Much is still not known and will only be revealed as more research is done with larger groups of patients.

As far as the $500 of tests that need to be done on the donor, I wonder if perhaps some of these could be eliminated. Clearly the donor should be checked for body fluid transmitted diseases such as HIV and hepatitis, though a family donor of known low risk (a child, for instance) might safely be presumed to be uninfected. Extensive stool testing for bacteria and parasites in a donor with no intestinal difficulties might also be unnecessary, especially if that person's history was well known.

As far as the actual logistics of delivering donor stool to recipient colon, I suspect nothing more than a commercially available enema bag and tubing would be necessary. The soup to be delivered could probably be easily and cleanly mixed up in a ziplock bag, with no need for a blender. As far as preparation with a clear liquid diet and gallons of polyethylene glycol, I am curious to see evidence that supports this (I don't think there is any, yet). Cleaning out the bad bugs seems like a good approach, but patients get very weak after a standard colonoscopy prep so a prep that includes days of fasting plus more polyethylene glycol might lead to its own problems.

I am starting to think about the nuts and bolts of all of this because, as a hospital physician, I will soon be faced with a patient for whom fecal transplant will be an obvious life saving intervention, and I will have to figure out how to do it with as little fuss as possible. It will be unethical for me to allow someone to die when antibiotics fail, as they so often do, when evidence shows that a fecal enema would probably be curative.


Anonymous said...

I am so glad you wrote this post!

I have autoimmune conditions, Fibromyalgia, Rosacea, Eczema, Arthritis, Brain Fog. I have had many antibiotics over my lifetime and steriods and SSRIs and I think it just pushed me over into autoimmunity and obesity. Docs don't offer this procedure to folks like me yet. Insurance wouldn't cover it either I am sure and paying thousands of dollars out of pocket is just not even possible.

I have been watchiing the Human Bionome Project but it has taken 5 yrs now and I bet trials will be next before anything concrete is available for patients. I am trying to find and decipher any results that have come of this study. Have you done this yet? If so you should blog about these results.

HNP was set to run five years and I think it started in 2007 so it should be wrapping up soon I would think. I do think it is the next big thing for medicine in general.

I read the pros and cons on the DIY stuff on home enimas for FT. I was not sure what all to consider in all of this. This post helped me with this.

Right now I am on meat only diet and can control autoimmune condition much better this way which tells me that I don't have the bio diversity to deal with carbs anymore. I also make sure I avoid ANYTHING that I swallow that contains antibacterial properties and cleaned up my water took out chlorine etc. No salt either. It really helped a lot but not the complete answer but in the righth direction. I came across this quote from the head of the HMP:

“Humans don't have all the enzymes we need to digest our own diet,” said Lita Proctor, Ph.D., NHGRI's HMP program manager. “Microbes in the gut break down many of the proteins, lipids and carbohydrates in our diet into nutrients that we can then absorb. Moreover, the microbes produce beneficial compounds, like vitamins and anti-inflammatories that our genome cannot produce.” Anti-inflammatories are compounds that regulate some of the immune system's response to disease, such as swelling.

I worry that I am not getting enough nutrients with meat only diet and that explains the ridges on my splitting nails etc.

This study suggests a three year old would make a good donor:

I would love to connect with a donor in Portland Oregon area and give this a go.

Probiotics don't work for me. Kefir and VSL#3 and vitamin D3 all give me a reaction of puffy face and blood shot eyes. Getting the right bacteria is key to this.

Also I do think there is more to this than just antibiotics. I think there could be multi causes too. GMO foods that contain new proteins that we just don't have the bacteria evolved yet to deal with it. I guess 80% of the foods we have are from GMO seeds. These new plants can contain new proteins that have pesticidal properties to them, thus they don't need so many pesticides, that cause intestinal permeability. We traded one evil pesticides for a GMO version that may really not work with our gut flora either.
Makes me want to live in Canada or Europe where they are much more careful about their food supply.

I can't beleive not one has posted a comment here since I think this subject is just huge.

Thanks for going out on the limb and posting this.

Dave said...

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Janice Boughton said...

Now the FDA apparently wants to regulate fecal transplants as "Investigational New Drugs." I read this link ( about IND's and it doesn't fit fecal transplants at all. First and most obvious, feces are not drugs. But, that aside, the IND is meant to clear a drug for transport across state lines, which feces do not need, and to establish safety before development and marketing. Prior to marketing poo, the poo should be tested. But I don't think anybody will successfully market it because it is rather widely available. Also poop is not one thing. It is not possible to test all feces for safety, and finding out that one sample was safe or unsafe would say absolutely nothing about another sample.

Tom said...

Amazing ! This is cool!

Janice Boughton said...

Not long after I wrote this I took care of a patient who had chronic C diff who was very ill and had not responded to antibiotics. We did a fecal transplant and it was quite easy. The patient's relative, who had been tested for communicable diseases, brought a stool sample in after taking a laxative, so the sample was quite liquid. The lab mixed it up with some saline (non-bacteriostatic)and delivered it to the nurse in a plastic bottle. The nurse delivered it as a retention enema. No fuss, no muss, and it appeared to work.

Janice Boughton said...

The FDA has backed off on regulating this.

Also physicians are have tried packaging a cleaned up version of healthy stool from a related donor, putting it in capsules so that the ick factor is reduced. This also appears to work.