The problem with fecal transplants

Over the past few years, we've linked to a couple of stories about fecal transplants—a real medical procedure where doctors take a donor stool sample, dilute it, and inject it into the colon of a patient. It sounds gross. But it appears to be incredibly effective at treating certain intestinal issues.

Basically, the fecal transplant is really a bacteria transplant. A fresh set of healthy bacteria can fix problems that aren't reliably treatable any other way. On the other hand, most of this information comes from anecdotal evidence. Fecal transplants haven't gone through any large-scale, randomized clinical trials. Until that happens, most doctors won't offer the procedure and insurance won't cover it. That makes sense. We rely on clinical trials to separate treatments that work from treatments that just appear to work. The problem with fecal transplant, though, is that it doesn't fit into any of the bureaucratic categories necessary to get a trial like that approved.

Over on Scientific American, Maryn McKenna has a great feature about fecal transplants—their promise, what we don't know about them, and what's keeping them from becoming a mainstream treatment.

Marion Browning of North Providence, R.I., was at her wit’s end. The 79-year-old retired nurse had suffered from chronic diarrhea for almost a year. It began after doctors prescribed antibiotics to treat her diverticulitis, a painful infection of small pouches in the wall of the colon. The regimen also killed friendly bacteria that lived in Browning’s intestines, allowing a toxin-producing organism known as Clostridium difficile to take over and begin eating away at the entire lining of her gut ... In the fall of 2009 Browning performed the bowel-cleansing routine that precedes a colonoscopy, while her son took an overnight laxative. Kelly diluted the donation, then used colonoscopy instruments to squirt the solution high up in Browning’s large intestine. The diarrhea resolved in two days and has never recurred.

Browning is not alone in being a success story. In medical journals, about a dozen clinicians in the U.S., Europe and Australia have described performing fecal transplants on about 300 C. difficile patients so far. More than 90 percent of those patients recovered completely, an unheard-of proportion. “There is no drug, for anything, that gets to 95 percent,” Kelly says. Plus, “it is cheap and it is safe,” says Lawrence Brandt, a professor of medicine and surgery at the Albert Einstein College of Medicine, who has been performing the procedure since 1999.

So far, though, fecal transplants remain a niche therapy, practiced only by gastroenterologists who work for broad-minded institutions and who have overcome the ick factor. To become widely accepted, recommended by professional societies and reimbursed by insurers, the transplants will need to be rigorously studied in a randomized clinical trial, in which people taking a treatment are assessed alongside people who are not. Kelly and several others have drafted a trial design to submit to the National Institutes of Health for grant funding. Yet an unexpected obstacle stands in their way: before the NIH approves any trial, the substance being studied must be granted “investigational” status by the Food and Drug Administration. The main categories under which the FDA considers things to be investigated are drugs, devices, and biological products such as vaccines and tissues. Feces simply do not fit into any of those categories.

Image: Toilet Roll, a Creative Commons Attribution (2.0) image from smemon's photostream


    1. He allowed his name to be attached to the medical school of Yeshiva University while it was under construction after hearing that admissions would be open to all religions and races, something that was unusual in the late 1940s.

  1. Diverticulitis is awful and I’m sure a course of antibiotics was preferable to surgery but if this was a “scorched earth” approach I wonder if it would be possible to store one’s intestinal flora before starting the antibiotics. Then, once the treatment was over you could “repopulate” your intestine from yourself instead of from a donor. I suppose there would be a concern for storing the bad with the good but my impression is with diverticulitis the bad is localized to the pockets.

    1. Or store some of your shit from an intestinally happier time, for use when you really need it later on.  Like people who keep their kids’ placental blood.  You could keep old toenails, haircuttings and baby teeth in the same nitrogen-cooled bio-locker.

    2. Why bother?  No matter how cheap they make poop storage I guarantee you can find an ample supply for free at a wide variety of locations at any time.

    3. Indeed, this is already being done in some cases. Just like banking your own blood. I forget the term used for it.

      1. I believe they are marketing it under the name Shitlocker.

        I personally am waiting for the turd of the month club.  Next month:  Nepal!  I just hope it comes inconspicuously packaged.

  2. probiotics in drug form are already available like erceflora.

    why not one by one find out exactly which bacterial species/species combination works then cleanly grow those in the lab and then place them in capsules which dissolve in the large intestine

    its the equivalent of moving from chewing on willow tree bark to aspirin

    1. The problem with this approach is that the bacterial population of the human GI tract is made up of hundreds of species, many (if not most) of which have yet to be identified or even well-described, creating an extremely complex self-correcting/limiting microbiome.  For all intents and purposes, the development of a product that even begins to approximate the early results of fecal transplantation is currently impossible and, ultimately, nonsensical.

      Aspirin vs. willow bark, or Marinol vs. marijuana for that matter, are perfect examples of why this approach really *doesn’t* work very well, honestly.  In the case of aspirin, 2-3 minutes of googling yields a plethora of information regarding the various other beneficial active compounds found in willow bark besides salicylic acid, including several compounds which act as prodrugs of salicylic acid (are converted to salicylic acid upon absorption) which neatly circumvent the GI issues that aspirin is known to cause.  Treatment with marinol frequently causes negative side-effects such as anxiety, nausea and dysphoria, which negatively impact any therapeutic effect and are generally absent when using whole preparations of marijuana.  I’m not saying that the sum action of whole products is always *better* than that of derivative products, but the effect of this approach is something to be aware of.

      tl;dr: Well-screened poop donors > billions spent on sanitizing the concept into a poor simulacra of poop.

  3. ‘In the U.S., however, the research logjam persists.’  *titter*

    ‘Increasing research interest in the influence of gut flora on the rest of the body—and on conditions as varied as obesity, anxiety and depression—will likely bring pressure for transplants to be adopted more widely.’

    In the future, I’d like to see this treatment used prophylactically.  There’s a huge number of us Boomers who were prescribed antibiotics for every little thing that happened to us when we were children.  While we may not suffer from C. diff per se (yet), Boomers seem to be a generation with chronic gut problems, even those leading a fairly clean and health lifestyle (cuz we want to live FOREVER and look good doing it!.)  I’ve wondered how many of those gut problems started in childhood and are organic in origin (as opposed to ‘it’s all on your head’ or ‘you’re getting older’.)

  4. If you imagine the old days like 100 years ago, and more usefully back to pre-agrarian times, you can’t help but imagine a world in which people are accidentally ingesting shit all the time. An okapi poops in the woods and a juicy mushroom grows up, Mog eats and refreshes Mog’s gut-florae. Also: open sewers.

    This is hygiene theory, the idea that our physical equilibrium is calibrated to a far more diverse and challenging environment than the one we post-industrial folk currently inhabit. Our bodies are a pyramid of little struggles, all balancing well enough to support a thick bundle of neurons which thinks of itself in the first person, with a severe distaste for feces.

    1. It’s based on this theory that researchers have been going into more agrarian cultures of late and collecting stool samples and studying the bacterial composition, exactly because they live closer to the land… by some coincidence, the folks in these cultures don’t suffer the gut problems us first worlders do.  They’ve found the composition to be more diverse, including what was considered rare strains of gut flora.
      The conversation around the campfire that night after the latest batch of scientists left must
      have been interesting, starting with… “What did they want from us this time?”

  5. Economies of scale have their dark side. By the time you want to add a new category of treatment, the infrastructure is too big to allow serious changes. It’s the same problem with insurance- there’s too much money at stake now to allow for change.

    (how is a turd transplant somehow more disgusting than a blood transplant? In context, both are equally interesting.)

  6. A major factor in the slow progress of this treatment (and others in the same category, for example, helminthic therapy – see is that they can’t be monetized by big pharma. Gastroenterologists who are open-minded enough to pursue this very promising treatment do not have armies of lobbyists to get their way.

    Also, a note to anyone who thinks this is funny or useless: spend just one hour with chronic C. Diff infection, Crohn’s disease, IBS or other serious intestinal malady, and you’ll be begging your creator and/or your doctor for relief. Poop jokes are funny, but intestinal disorders are awful.

    1. Chronic constipation ain’t no picnic either.  Just want to give a shout out to those of us who know the grass isn’t any greener on this side of the malady.

      1.  No it’s not, my sister can go 3 weeks, without a BM, and has seen atleast 8 gastros, taken every possible remedy. The general consensus is that the muscles around her intestines don’t fire in order.

  7. I’ve been trying to conceive a way to get my partners gut fauna inside my stomach for a while. She seems to be able to eat absolutely anything without getting any issues whilst I am nearly constantly suffering gut problems of one sort or another.

    If I manage to eat yoghurt every morning the problems are certainly alleviated, but two days without and they back rapidly. Indicating gut fauna is at least part of the problem and that my stomach doesn’t seem to stay “in balance” by itself. My almost entirely uneducated intuition makes me believe there is some other kind of fauna present in most peoples gut, that’s not in mine that helps other bacteria survive for longer periods of time without… aherm… shit going haywire .

  8. I’ve been trying Florastor, it’s a proprietary probiotic, a type of yeast saccheromyces boulardii, and it really has worked to keep the bad side effects from an extended regimen of antibiotics (diarrhea, c.difficile, etc.)  from being an issue.  I found out about it from an old CNN article, they talk about other probiotics that work for specific issues, citing actual studies n’ stuff.

    Florastor is over the counter, but not cheap.  Worth every penny in my recent experience.

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