Got UC? What You Should Know About Fecal Transplants
Everything you (n)ever wanted to know about using (yes) poop to treat ulcerative colitis.
Editor's Note: This story is part of a new series on HealthCentral called "Get Your Ph.D.!", which is geared toward people who've got the basics of their condition down and want to up their expertise. Who's ready to go pro?!
If you're dealing with UC, no one needs to tell you how uncomfortable—scratch that, downright awful—it can be at times. When it’s not causing pain, it’s likely still causing awkward social moments and serious stress, as you spend your life making sure you know where the nearest bathroom is.
If you’ve tried the traditional path of immunomodulators and biologics, and you’re still doing battle with your gut, your doctor may have mentioned surgery, a procedure that could put an end to some of your challenges—but also create a host of new ones.
Now, though, you have another option to consider: A fecal transplant. We know, we know—cue the potty jokes. But when you're done laughing, consider this: The transplantation of fecal bacteria is a relatively new and potentially promising field aimed at reprogramming your gut microbiome as a way to possibly ease UC flares and perhaps reverse disease progression when other treatments have failed. So how exactly does it work? Read on.
Fecal Transplant 101
Though the term “fecal transplant” is casually used by the public, the full medical term for the procedure is “fecal microbiota transplant” (FMT). That matters, because while the first term conjures up a mental image of moving a piece of poop from one person to another, the second describes what really happens: a purified sample of fecal material containing gut bacteria (and other microbes, hence the word microbiota) is transplanted from a healthy donor to a person who has UC.
It may seem like an odd path of investigation, given that UC has long been thought of as an autoimmune disease, where the body’s immune system—normally responsible for killing off invading bacteria and viruses—attacks its own gut tissues instead, resulting in chronic inflammation. But recently, scientists have begun considering evidence that the disease is associated with a dysfunctional gut microbiome. (In a healthy microbiome, good gut bacteria typically protect the intestine from harmful bacteria that could invade.)
“The stool of patients with UC have an abnormal fecal microbial population with decreases in bacterial diversity,” says Jeffry A. Katz, M.D., a professor of medicine at Case Western Reserve University School of Medicine in Cleveland, OH. “Replacing this abnormal stool with a more ‘normal’ stool could potentially mitigate the disease severity by establishing a healthier and more diverse bacterial population within the colon.”
In other words, the guts of people with UC have fewer types of bacteria, as well as fewer numbers of beneficial bacteria (such as Lactobacillus, Bacteroides, or Ruminococcus). In addition, scientists believe the guts of people with UC may contain more bacteria species that are disease causers, compared with healthy people.
Finding Fecal Transplant Candidates
If you’re interested in getting a fecal transplant for your UC, you’ll need to meet certain criteria first: The Food and Drug Administration (FDA) reserves the procedure for people who have a specific bacterial infection (Clostridium difficile or C. difficile). UC increases the risk for this potentially fatal infection, which can occur after taking certain antibiotics.
If you don’t have a C. difficile infection, you can still get a fecal transplant, but it's more complicated. “It requires an FDA-approved investigational new drug application” before getting a transplant, says Berkeley Limketkai, M.D, Ph.D., an associate clinical professor at the David Geffen School of Medicine at the University of California Los Angeles. (To identify institutions doing FMT studies, go to clinicaltrials.gov/ and search for “fecal microbiota transplant.” Schedule an appointment with the doctor running the study to see if you can participate.)
If you qualify for a fecal transplant, you’ll be happy to know the poop you receive has gone through quite the vetting process. All donor stool is screened for disease-causing bacteria, viruses, and parasites to reduce any risk that these pathogens could transmit a potentially life-threatening infection to the recipient. As for where it comes from, most institutions either rely on stool from commercial vendors (donor banks) or, says Dr. Katz, “a group of stool donors may be used.”
How Fecal Transplants Work
Once you’ve been accepted as a transplant recipient, here’s what you can expect (warning: we’re about to get graphic.) The procedure falls into one of two broad categories: those that deliver the poop (frozen, then thawed) from above, and those that deliver it from below. The former includes capsules that you swallow or receive as liquid via a naso-gastric or NG tube that’s threaded from your nose into your gut. The second category either involves your physician inserting the fecal material using an enema or delivering it via a colonoscopy (the more common method).
If capsules are used, you may need to swallow dozens of these fecal material-filled pods over a period of a day or several days. When the colonoscopy method is used, the fecal material is put into the scope that’s inserted in the rectum and snaked into the large intestine. As the scope is pulled back out, the fecal material is released.
Is one method better than another? Hard to say just yet. Of the four controlled studies that have been published, those using colonoscopy or an enema “showed a clinical remission of symptoms by 24% to 50%—that’s a significant benefit,” says Dr. Limketkai, adding that 55% of those using a colonoscopy had no inflammation in the colon after the procedure.
If you’ve read this far and you’re still inclined to give it a try, your next step will be to talk with your doctor about the specifics of procedure preparation, which will likely be done as an outpatient. For instance, you'll need to stop all antibiotics 48 hours before to assure that the microbiome in the fecal material you receive is not killed.
Often, your physician will discuss how to make sure your gut is empty by, for example, advising you not to eat any solid food up to 24 hours or so before the procedure and only drinking clear liquids. (For the colonoscopy method, the bowel prep is what you would expect for a typical colonoscopy.) If you’re undergoing the NG tube procedure or taking the capsules, you may be told to take a proton-pump inhibitor such as Prilosec (omeprazole) a day or so before the procedure. This is done to reduce stomach acids, which could knock off the beneficial microbes in the stool sample.
Life After a Fecal Transplant
So how will your body react to being introduced to someone else’s “poop”? “Most reactions are mild and self-limited, but may include abdominal discomfort, nausea, and changes in stool frequency,” such as constipation or diarrhea, according to Benjamin Cohen, M.D., co-section head and clinical director of the Inflammatory Bowel Disease, Digestive Disease & Surgery Institute at the Cleveland Clinic in Ohio.
If a colonoscopy is done, there’s a risk of bleeding or the bowel getting torn (perforated). If you were given a sedative for the colonoscopy, you’ll be monitored in the outpatient facility until it wears off, and then a friend or relative will have to accompany you home. If you took the capsules or had the NG tube method, you may be told to fast for an hour or so after the procedure.
Because of its relative newness, experts still aren’t sure how a fecal transplant might affect you five or 10 years from now. “We don’t know the long-term effects. So far, they have been relatively safe,” says Dr. Limketkai. Rarely, there have been reports of patients becoming infected with a drug-resistant microbe from the donor’s fecal material, and there have also been a few deaths. And despite its promise, the procedure is not a cure-all. “There are reports of patients having their colitis actually worsen after FMT for UC,” says Dr. Katz.
As scientists continue to learn the ins and outs, so to speak, of the FMT procedures, it’s still unknown which microbes in the fecal material could “breed” the most success in helping re-set the gut microbiome of someone with UC. “We don’t know the best combination of bugs—some people’s poop seems better than others—the so called ‘super donors,’” says Dr. Katz. #Superpoopers? The irony is not lost on people with UC.
Super Poop Donors: Frontiers in Cellular and Infection Microbiology. (2019). “The Super-Donor Phenomenon in Fecal Microbiota Transplantation.” ncbi.nlm.nih.gov/pmc/articles/PMC6348388/
Fecal Transplant Overview: JAMA. (2017). “Fecal Microbiota Transplantation.” jamanetwork.com/journals/jama/fullarticle/2635633
Fecal Transplants and Ulcerative Colitis: BMC Gastroenterology. (2019). “Fecal microbiota transplantation for ulcerative colitis: a prospective clinical study.” bmcgastroenterol.biomedcentral.com/articles/10.1186/s12876-019-1010-4
Fecal Transplants and UC Benefits: Therapeutics Advances in Gastroenterology. (2019). “Insights into the role of fecal microbiota transplantation for the treatment of inflammatory bowel disease.” ncbi.nlm.nih.gov/pmc/articles/PMC6421596/
Fecal Transplants and Future: Transplantational Gastroenterology and Hepatology. (2019). “Fecal microbiota transplantation for ulcerative colitis—where to from here?” ncbi.nlm.nih.gov/pmc/articles/PMC6624363/