All About Poop Transplants

Fecal transplants have many names–poop transplants, fecal microbiota transplants, intestinal microbiota transplants, human probiotic infusion, stool transplant, and bacteriotherapy to name a few.  Basically, a fecal transplant is taking someone’s poop and putting it inside of someone else’s colon.  Fecal transplants started in China in the 300s as “yellow soup” which was made of fecal matter (aka poop) and water, and then drunk by the patient.  Modern medicine no longer requires drinking yellow soup, instead using colonoscopies, nasoduodenal tube (from your nose to just past your stomach), enemas, and pills.  

Fecal transplants appeared briefly in the USA in 1958 when a Colorado doctor used fecal enemas to cure 4 people that were critically ill with an infection now known to be caused by C. Diff (more on C. Diff later).  Fecal transplants have been performed in Australia since 1988, and worldwide interest surged again in 2012 and 2013 [1].

yummy

Pumpkin soup/ Image available under CC0

Clostridium Difficile

A lush garden with a variety of plants / Image available under CC0

A lush garden with a variety of plants / Image available under CC0

In a healthy colon, there are thousands of bacteria flourishing.  This bacteria is helpful to the human, providing nutrients like Vitamins B and K and breaking down bile and other substances.

A course of antibiotics will kill the bad bacteria in your body but also the good bacteria.  After taking broad spectrum antibiotics or a long course of antibiotics, your colon can be left defenseless.  As your colon recovers from the antibiotics, a bacteria named Clostridium Difficile, commonly known as C. Diff, can take over.  It overgrows, and then releases toxins that attack the lining of the intestines.  C. Diff colitis has symptoms similar to severe food poisoning.  It causes watery diarrhea, abdominal pain, and tenderness at the least.  More severe cases would have symptoms of bloody and or mucousy stools and watery diarrhea up to 15 times a day.  In addition to the serious health effects this causes, it also significantly affects the quality of life for the patient.  If the C. Diff toxins eat a hole into the lining of the intestines, the resulting infection can be fatal if not treated immediately [2].  The common course of treatment for C. Diff is more antibiotics.  Unsurprisingly, the success rate is low (didn’t antibiotics cause the problem in the first place?).  A clinical trial from the Netherlands showed a 23%-31% success rate for the antibiotic Vancomycin [3].  C. Diff is contagious–infected poop releases spores that can live in the open air, surfaces or in dirt for up to two years [2], so make sure to wash your hands if you are in contact with someone infected with C. Diff.

Clostridium Difficile bacteria as seen under a scanning electron microscope

Clostridium Difficile bacteria as seen under a scanning electron microscope/ Image available under public domain

What is a fecal transplant?

For a person suffering from an infection of C. Diff, a fecal transplant is over 90% effective [4], which is significantly higher than antibiotics.

A fecal transplant involves taking poop from a healthy donor who has been meticulously screened (see below for donor info).  Then it is mixed into a slurry with either distilled water or a saline solution.  The slurry can be mixed using a blender (smoothies, anyone?) or shaken by hand in a small container.  Then the donor poop slurry is transplanted into the patient during a colonoscopy.  Recipients feel better within hours and are nearly back to normal a couple of days post treatment [5].  

Chocolate milk + cookies

Donation poop may be blended to prep for a transplant / Photo by Bodymybody.com

To prep for a colonoscopy and transplant, the patient has cleaned out as much out of their own intestines with a liquid diet and a laxative or an enema.  The prep is mandatory for the colonoscopy itself, but also provides a clean (as good as it will get anyways) slate for the new donor bacteria to populate.

The average fecal transplant recipient is not typically put off by the “ick” factor of having another person’s poop injected into their colon–rather it is usually the opposite.  This person has likely been through months, if not years of bloody diarrhea and has tried many other solutions that have failed.  Because of the perceived ick factor by some doctors, researchers, and patients and lack of research on long term impacts of fecal transplants, the procedure is generally considered a last resort.  However, patients are beginning to push for a fecal transplant first, instead of the antibiotics, because of its effectiveness on fighting the infection and being cost effective [5].

Besides colonoscopy, other methods of delivery can be used–fecal enemas, donor poop slurry delivered down a tube from the nose to just past the stomach (called a nasoduodenal procedure), or taking 30 frozen capsules filled with concentrated formulas of “microbiota” (donor poop that has been prepped for transplant).  The pills are the size of a large multivitamin, are delivered to the doctor’s office on dry ice and then continued to be frozen until being taken all at once under the supervision of the doctor [6].  The pills are just as effective as the colonoscopy and are about half the price–$535 for the pill therapy [6], around $1200 for colonoscopy delivery [7] (at the time of the publication of this post).

The frozen capsules with concentrated formulas of microbiota look similar to these natural supplement pills

The frozen capsules with concentrated formulas of microbiota look similar to these natural supplements / Photo by freeimages.com/tinpalace

Be a donor!

You don’t necessarily have to be related to a C. Diff patient to be a donor.  You do however, have to pass a rigorous battery of tests.  Open Biome, the go-to bank for transplantable poop, accepts only 3% of applicants.  To be a donor there, you have to undergo a 185 question interview with an internal medicine specialist [8].  If you pass that, then there are blood and stool screenings.  After passing that, you can donate your poop!  You have to go to their lab to “deposit” your donation 5 times a week for 60 days, with your health being periodically checked.  60 days after your last donation, your health is again checked.  Following a clean bill of health, the poop is processed and sent to recipients all over the country [9].  This is quite the commitment, but don’t worry, for every stool donated, you are compensated $40 [9].  That is some nice change for a normal daily activity!  For those of you on the West Coast, a new stool bank opened in February of 2015 [10], AdvancingBio.  As more restrictions are placed on stool banks and hospitals (see next paragraph), local hospitals performing fecal transplants may also be in need of donors.  

Is he playing Frogger?

A frog donating poop / Image available under CC0

Why Fecal Transplant is Not More Popular

The US Food and Drug Administration regulates fecal transplants.  The regulation allows for doctors to only do a fecal transplant for those patients not responding to standard C. Diff therapy.  Note the wording–doctors cannot perform a fecal transplant until other options have been attempted.  This frustrates many patients and doctors!  If doctors want to use fecal transplant for anything except recurrent C. Diff, the doctor has to file an authorization for an investigative new drug [11], which could take months or years [12].  Because of this restriction, finding a doctor able to perform a transplant for your ulcerative colitis may be extremely difficult or impossible.

The concern behind this regulation is the unknown.  HIV, hepatitis, viruses, parasites, unidentified pathogens can all be present in a donor stool.  Additionally, the long term effects and effects of repeated transplants have not been studied.

Recently, the FDA placed another restriction on donor samples.  Now the patient or the doctor has to personally know the donor (which makes it difficult to order poop pills from the national stool banks).  This is supposed to protect the patient from unknown donors and their diseases, but the reality is that it has made the fecal transplant slightly more difficult, time consuming, and expensive.  A recipient needs to find a willing donor, who then needs to undergo a battery of medical tests.

Another hurdle is insurance.  Many insurance companies will not cover the cost of a fecal transplant (although some will cover the cost of the colonoscopy that delivers the fecal transplant) [13], because it is considered an experimental procedure under the FDA and insurance doesn’t have to cover experimental procedures [7].

Other uses

Fecal transplants are currently being investigated as a potential cure for other diseases–obesity [14], insulin resistance [15], chronic fatigue syndrome, irritable bowel syndrome, Parkinson’s, multiple sclerosis, autism, crohn’s, ulcerative colitis [16] and more.  However, unless you are part of an approved clinical trial, there is currently no medically provided fecal transplant option for anything except a recurrent C. Diff infection [17].

DIY

Ready for some DIY?

Ready for some DIY?/ Image available under CC0

Unfortunately, those needing a fecal transplant but are not suffering from a C. Diff infection are out of luck unless they get accepted into a medical study.   People facing surgery to remove intestines or those that have been through years of bloody diarrhea may be left to their own creativity and risky DIY procedures at home.  I definitely don’t condone or recommend the DIY route, as fecal transplants are best performed under a healthcare provider.  However,  a simple google and youtube search will help you find a variety of resources showing you how to DIY.  

My Conclusions

After getting past the ickiness of the idea, many doctors and patients are seeing the promising potential of fecal transplants.  Fecal transplants for recurring C. Diff infections are just the tip of the iceberg–it will be interesting to see what develops!

Ice

Ice / Photo By Jeremy Ricketts


References:

[1]      Fecal Microbiota Transplant.” Wikipedia. Wikimedia Foundation, 07 Sept. 2016. Web. 03 Oct. 2016.

[2]      C. Diff: Causes, Symptoms, and Treatments.” WebMD. WebMD, 13 Apr. 2015. Web. 03 Oct. 2016.

[3]      Duodenal Infusion of Donor Feces for Recurrent Clostridium Difficile.The New England Journal of Medicine 368 (2013): 407-15. New England Journal of Medicine. NEJM Group, 16 Jan. 2013. Web. 7 Oct. 2016.

[4]      Oprita, R., M. Bratu, B. Oprita, and B. Diaconescu. “Fecal Transplantation – the New, Inexpensive, Safe, and Rapidly Effective Approach in the Treatment of Gastrointestinal Tract Diseases.Journal of Medicine and Life 9.2 (2016): 160-62. US Library of Medicine National Institutes of Health. Carol Davila University Press, Spring 2016. Web. 06 Oct. 2016.                          

[5]      Mckenna, Maryn. “Why Would Anyone Get a Fecal Transplant? Watch a Brother and Sister Explain.” Phenomena. National Geographic, 22 June 2015. Web. 04 Oct. 2016.

[6]      FMT Capsule G3.” OpenBiome. OpenBiome. Web. 04 Oct. 2016.

[7]     Mulder, James T. “Poop Transplants: Does Insurance Pay for Life-saving Treatment?Syracuse.com. Syracuse Media Group, 24 Mar. 2015. Web. 09 Oct. 2016.

[8]      Quality & Safety.” OpenBiome. OpenBiome. Web. 05 Oct. 2016.

[9]      Stool Donation.” OpenBiome. OpenBiome. Web. 04 Oct. 2016.

[10]      Lowes, Robert. “FDA Proposes Tighter Rules for Fecal Transplants.” Medscape. Medscape, 16 Mar. 2016. Web. 05 Oct. 2016.

[11]     Fecal Microbiota Transplantation.” IDSA. Infectious Diseases Society of America. Web. 05 Oct. 2016.

[12]      CBS News/AP. “FDA Struggles to Regulate Fecal Transplants.” CBSNews. CBS Interactive, 26 June 2014. Web. 05 Oct. 2016.

[13]     Frequently Asked Questions.” The Fecal Transplant Foundation. The Fecal Transplant Foundation. Web. 03 Oct. 2016.

[14]     FATLOSE Trial: Fecal Administration to LOSE Weight.” Nederlands Trial Register. Nederlands Trial Register, 24 Apr. 2009. Web. 05 Oct. 2016.

[15]     FATLOSE 2 Trial (Fecal Administration to LOSE Insulin Resistance).”Nederlands Trial Register. Nederlands Trial Register, 18 Jan. 2011. Web. 05 Oct. 2016.

[16]     Evrensel, Alper, and Mehmet Emin Ceylan. “Fecal Microbiota Transplantation and Its Usage in Neuropsychiatric Disorders.Clinical Psychopharmacology and Neuroscience 14.3 (2016): 231-37. Clinical Psychopharmacology and Neuroscience. Korean College of Neuropsychopharmacology, 31 Aug. 2016. Web. 06 Oct. 2016.

[17]     Providers & Trials.” The Fecal Transplant Foundation. The Fecal Transplant Foundation. Web. 05 Oct. 2016.


 

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