May 16, 2011 -- Demonstrating that even in medicine, "one man's trash is another man's treasure," patients with debilitating diarrhea are finding relief, if not cures, after receiving bacteria-rich stool from the guts of healthy donors, usually close relatives.
Despite the gross-out factor, fecal transplants are simple enough to perform at home using such inexpensive tools as a bottle of saline, a 2-quart enema kit from the local drugstore and a standard kitchen blender.
"Some of my patients tell me within three hours of having this that they feel better," said Dr. Lawrence J. Brandt, emeritus chief of gastroenterology at Montefiore Medical Center in the Bronx, N.Y., who has performed about 25 fecal transplants since 1999.
The approach, also called fecal bacteriotherapy, is hardly new. Dr. Ben Eiseman, the longtime chief of surgery at Denver General Hospital, reported in the Journal of Clinical Gastroenterology in 1958 that enemas containing feces from healthy colons successfully replenished good digestive bacteria in patients suffering from pseudomembranous colitis, a painful colon inflammation associated with a bacterium called Clostridium difficile. Dr. Thomas J. Borody, from the Centre for Digestive Diseases in Sydney, Australia, reported in the same journal in 2003 that "human probiotic infusions" reversed ulcerative colitis in six patients, each of whom had been sick at least five years with the inflammatory condition. All remained disease-free in one to 13 years of follow-up.
In recent years, the number of chronic infections with C. diff has increased, often from prolonged antibiotic use and growing antibiotic resistance, especially among the elderly and those in hospitals and long-term care facilities. That has driven renewed interest in fecal transplantation, although it's still not covered by health insurance plans.
North American gastroenterologists and infectious disease experts, mindful that the technique has been used in Europe, have been offering it as last-ditch therapy for patients wasting away from debilitating diarrhea that hasn't responded to even the most powerful and most expensive antibiotics, such as vancomycin.
Dr. Alexander Khoruts, a gastroenterologist at the University of Minnesota, reported in the Journal of Clinical Gastroenterology in June about a desperately ill C. diff patient cured within a day of receiving an infusion containing fecal bacteria from her husband. Khoruts and his colleagues demonstrated that her husband's healthy bacteria repopulated her gut and made it healthy, too.
Doctors infuse patients' colons using an enema or colonoscope (and sometimes the stomach using a nasogastric tube) with solutions of water or saline spiked with donor feces that have been screened for parasites, HIV, hepatitis, and other illness-causing microbes. They suggest donors should be someone you know and trust, like a spouse, a parent or a child, although a few institutions are experimenting with donations collected from healthy men or women who have been tested and found free of major diseases.
"This form of therapy has now reached primetime," Dr. Martin H. Floch, a digestive disease specialist at the Yale School of Medicine, declared in an editorial accompanying three studies of fecal transplantation in the September 2010 issue of the Journal of Clinical Gastroenterology. "Although there are some skeptics, it is clear from all of these reports that fecal bacteriotherapy using donor stool has arrived as a successful therapy."
Studies Find Transplanted Fecal Bacteria Take Hold and Multiply in Recipient's Gut
In the journal:
Martin J. Grehan, a gastroenterology researcher at Penrith Hospital in Sydney, Australia, and his colleagues reported that up to six months after the transplants, C. diff patients' feces predominantly contained bacteria varieties from the healthy donor. Floch called Grehan's study a landmark that suggested transplants have promise "for new therapies in the treatment of colonic or metabolic disease."
Montefiore's Brandt reported on a dozen cases in which C. diff patients got lasting results. He concluded that fecal transplantation is safe and effective. In an interview Friday, he said that he and Dr. Colleen Kelly, a Rhode Island gastroenterologist, have submitted to the National Institutes of Health a proposal for a randomized, controlled clinical trial of 40 patients, which he hopes would generate the kind of data to convince "the medical community at large" that the technique works.
Dr. Neil Stollman of Northern California Gastroenterology Consultants in Oakland, Calif., reported on a study in which 18 of 19 patients with recurring C. diff infections responded to a single infusion of transplanted feces, and the treatment eradicated the C. diff in all 19.
Floch wrote that acceptance of this therapy won't be easy because "it holds certain anxieties for the patient." Another hurdle, he suggested, was defining "how this therapy can become socially accepted."
Dr. Michael S. Silverman, an infectious diseases specialist at the University of Toronto, reported in the Feb. 1, 2010, online edition of the journal of Clinical Gastroenterology and Hepatology on seven cases in which do-it-yourselfers achieved "100 percent clinical success." They received step-by-step instructions about how to mix a small quantity of stool (1.7 ounces) with slightly less than 7 ounces of saline in a blender until it reaches "milkshake" consistency, pour the mixture into an enema bag and then administer according to directions provided with the enema bag kit.
"Making this approach available in health care settings has the potential to dramatically increase the number of patients who could benefit from this therapy," Silverman wrote.
Researchers Trying Fecal Transplants in Obesity, Neurological Disorders
Scientists are testing fecal transplants in other maladies. Dutch researchers reported in September on a small, early study in which obese patients underwent fecal transplants from healthy, thin donors. They told colleagues at the European Association for the Study of Diabetes meeting that the transplants improved insulin sensitivity among obese patients with metabolic syndrome, which elevates risk for heart attack, stroke and diabetes, and reduced their triglyceride levels.
Australia's Borody, a gastroenterologist who has studied fecal transplantation for more than 30 years, has begun exploring the technique's potential in treating neurological disorders, after finding that fecal transplants given to constipated patients who had Parkinson's disease seemed to lessen their neurological symptoms along with their digestive distress.