Everyone has heard of corneal transplants, kidney transplants, and liver transplants, but NOT everyone has heard of FECAL TRANSPLANTS. Yes, that’s right; a fecal transplant. You mean someone’s bowel waste (Feces) is transplanted into another person? That really happens? Yes, it does and it works very well.
I vividly remember the first time I heard of fecal transplantation; it was about 10 years ago during a continuing medical education (CME) seminar conducted by the Mayo Clinic. A gastroenterologist from Mayo in Jacksonville, Florida, had the audience squirming in their seats when he explained how liquified stool material from one person was given to another patient through a plastic nasogastric tube. The explanation of the procedure brought about a lot of “ooh’s,” “ugh’s,” and “no way’s” from many listeners. The visions and odors I conjured in my mind were too much!
Since 2013, when the US FDA approved the procedure as treatment for a specific problem, much research has been done, and it has become accepted treatment for several disorders. More detail about fecal transplantation will be presented later.
The official name is FECAL MICROBIOTA TRANSPLANTATION (FMT). What it does is replace or normalize the bacterial content of the intestinal tract. Many disorders, especially gastrointestinal diseases, are caused by changes in the type and amount of bacteria in the gut. Everyone has bacteria that grow in their intestines. This is called the Intestinal (or gut) Flora. It is there to assist in digestion and absorption of nutrients.
An imbalance of the normal flora, called DYSBIOSIS, is associated with numerous problems, of both GI and non-GI origin. The most frequent problem for which FMT is done is Clostridium difficile infection (CDI). CDI occurs after patients have taken antibiotics for some other reason. Those antibiotics disrupt the normal bacterial flora balance. That causes chronic diarrhea among other things. Before FMT, CDI was treated with IV and/or oral antibiotics of another type. This treatment was successful only 30% of the time, at best, and often had to be prescribed repeatedly. FMT, on the other hand, has a 90% cure rate in recurrent of refractory (resistant to treatment) cases of CDI. That is a much more acceptable result.
WHAT IS THE PROCEDURE?
Fecal Donors: Suitable, healthy donors should be evaluated within 4 weeks before donation:
Spouse or close relative is the ideal donor
Extensive Blood and stool examinations are done
Patient must meet these criteria:
No history of GI symptoms or disease—eg. Inflammatory Bowel Disease, GI Cancer, etc.
No active medical diseases—esp. HIV, Hep B, Hep C, Diabetes, Immunosuppression
No illicit drugs, recent tattoos, risky sexual behavior, remote travel
No chemotherapy drugs, immunosuppressants
No MS, asthma, metabolic syndrome, malignancy, etc.
Fecal Recipients: Anyone with a disorder helped by FMT
No antibiotics 12-48 hours before transplant
Standard bowel prep-like before a colonoscopy
Lomotil orally one hour before FMT to ensure feces remains in the colon for 4 hours
Fecal Transplant Specimen Preparation:
Specimens are either fresh or frozen
Approximately 50 gm of donor feces is mixed with 150 ml of sterile normal saline in a
blender
Mixture is filtered to clear large particles
Specimen can be stored at room temperature or frozen for later use
Stool banks have been established worldwide for prescreened, recurrent donor feces
Transplant must be done within 6 hours of preparation or thawing
How is Feces delivered:
Upper GI Route: Through a tube passed through the nose into the stomach, duodenum,
or jejunum (second part of small intestine). Or by an Oral capsule
Lower GI Route: Through a colonoscopy tube into the lower end of the colon
How much liquid is given? Larger volumes of fecal material have shown to be have better
results in CDI, but the exact volume is unknown. 50 gms or more are recommended
WHY IS FMT DONE?
More and more disorders have been found to have a connection to Intestinal DYSBIOSIS.
Obviously, conditions that involve the intestinal tract are more likely to be helped by FMT.
Clostridium difficile infection (CDI), a very stubborn disorder is cured by FMT 90% of the
time. Inflammatory bowel disease (IBD-Ulcerative Colitis, Crohn’s Disease), and Functional
Bowel Disease (Irritable bowel syndrome-constipation, diarrhea types) are helped.
Metabolic Syndrome (Diabetes, High Cholesterol, High Triglyceride, Large Waist
Circumference), Obesity
Multiple Sclerosis, Chronic Liver Failure with Neurologic Symptoms
Autism-empiric treatment has improved autistic children
Multiple studies have been done to evaluate FMT treatment for CDI. It has repeatedly been shown this technique is far better than any other for eliminating the problem and bringing about remission. The rectal route of administration seems to be more effective. When I think about having a FMT myself, watching fecal material enter my body through a tube in my nose, gives me “the willies!” It just isn’t a pleasant thought. But, if I were asleep, and it was given through a colonoscope, I would be completely unaware of it. I would prefer not to know it’s happening.
FMT is not without adverse effects. Abdominal pain, nausea, flatulence, bloating, headache, dizziness, and fever can occur, but only 7% of recipients have adverse events. The rates of remission for CDI and IBD far outweigh any problems. Long term events or safety concerns have yet to be determined.
Stool banks seem like an esthetically unpleasant concept, but because they exist, Fecal Microbiota Transplants are more accessible for patients who need them. Clostridium difficile infection was becoming a frequent occurrence before I retired 7 years ago, and I know the incidence hasn’t declined since. Broad spectrum (wide variety of treatable infections) antibiotics are being used all the time so CDI is more likely to happen. FMT would probably be reserved for a stubborn case of CDI. Standard antibiotic treatment would be tried first, but you have FMT to rely on later. It is an “invasive procedure” requiring preparation, so you don’t do it at the drop of a hat.
One FMT success story was in an article in Discover Magazine. A 7-year old boy, Ethan, suffered from autism, chronic diarrhea, constipation, cramping, and severe pain with bowel movements. He was irritable, had frequent outbursts of hostility, slow language development, argued, fought and pushed others. Weeks after a fecal transplant, his demeanor changed. He awoke happy, smiling, and “was ready for the day.” After a year, his speech pattern and communication skills improved to the point his speech therapist graduated him from therapy. His GI symptoms resolved as well. His mother was encouraged that he could “navigate the world when I’m not here.”
FMT does seem like an effective procedure. A “two-year follow-up suggested that FMT is relatively safe and effective in significantly reducing gastrointestinal disorders and autism symptoms…” If one can get past the idea of having fecal material put into oneself through a tube in one’s nose, the rest is easy. It’s simply a matter of allowing the concept to do what it’s supposed to do. FMT is one of those new ideas that may have more uses than we now appreciate. Many more experimental investigations are needed to determine what other disorders may have an intestinal flora basis and are amenable to this treatment. The surface may have only been scratched.
References: Wang JW, et al. Fecal Microbiota transplantation: Review and Update J Formosan Med Assoc 2019 Mar;118(1):S23-S31.
Adams JB, et al. Microbiota transplant therapy and autism: lessons for the clinic Expert Rev Gastro Hepatol 2019 Nov;13(11):1033-1037.
Choi HH, Cho YS Fecal Microbiota Transplantation: Current Applications, Effectiveness, and Future Perspectives Clin Endosc 2016 May;49(3):257-265.
Imdad A, Nicholson MR, et al. Cochrane Database Syst Rev 2018 Nov 13;11(11):CD012774.
Ooijevaar RE, Terveer EM, et al. Clinical Application and potential of Fecal Microbiota Transplantation Annu Rev Med 2019 Jan 27;70:335-351.
Bibbo S, Ianiro G, et al. Fecal Microbiota transplantation: past, present, and future perspectives. Minerva Gastroenterol Dietol 2017 Dec;63(4):420-430.
Li N, Tian H Current research progress and thinking of fecal Microbiota transplantation for the treatment of gastrointestinal disorders. Zhonghua Wei Chang Wai Ke Za Zhi 2017 Oct 25;20(10):1104-1108.
Kelly CR, et al. Effect of fecal Microbiota transplantation on recurrence in multiply recurrent Clostridium difficile infection: A randomized trial. Ann Intern Med 2016 Nov 1;165(9):609-616.
Vindigni SM, Surawicz CM Fecal Microbiota Transplantation Gastroenterol Clin North Amer 2017 Mar;46(1):171-185.
HTTPS://www.discovermagazine.com/health/autisms-gut-connection-microbes-could-soon-lead-to-new-treatments
