The Enema of Your Enemy is Your Friend
Fecal transplants could be a cheap and effective treatment for gastrointestinal disorders.
It's true there's been no major clinical trial of fecal transplants, but the procedure appears in the medical literature at least as far back as 1958. That's when a Denver-based surgeon named Ben Eiseman performed four of the procedures to rid patients of a form of colitis thought to be caused by C. diff. His plan was to administer "normal feces into the colon of patients with the disease," so as to "re-establish the balance of nature." Three of his four patients were near death before the fecal enema. After, they recovered. This small experiment suggested a "simple yet rational therapeutic method," Eiseman and his colleagues wrote, that deserved careful evaluation.
Now we're beginning to see some more extensive studies. Mark Mellow, a gastroenterologist at INTEGRIS Health in Oklahoma City, recently presented a paper showing that 15 out of 16 C. diff patients whom he'd provided with a fecal transplant remained disease-free after five months. Several other papers presented at the meeting showed similar positive effects, and in every case, symptoms disappeared almost immediately after the transplant.
Still, the evidence supporting fecal transplant comprises just about 20 published case reports involving about 200 patients. Until a large-scale, randomized trial is published in a big-name medical journal, most doctors will likely follow the example of the University of Toronto and hold off on performing the transplant. Indeed, relatively few gastroenterologists have even tried it. Colleen Kelly, a gastroenterologist at Women & Infants Hospital of Rhode Island, surveyed 72 gastroenterologists at a recent international medical meeting and found that only seven had performed the procedure. Nearly half said they'd be willing to perform a transplant on a sick patient, but the rest said they weren't ready yet. "I really think in another couple of years, it's going to be something that everyone's doing," said Kelly, who has performed the operation 22 times herself.
Infectious-disease experts are a little more tempered in their enthusiasm. According to Vincent Young of the University of Michigan, the data look promising but he wouldn't perform a fecal transplant himself because there are too many unknowns about what bad things might be lurking in a stool sample. William Schaffner, president of the National Foundation for Infectious Diseases, warned that the procedure is still in its early days and not yet ready for prime time. (The American College of Gastroenterology, for its part, has no official position on fecal transplants.)
But the true believers have even bigger plans. They hope fecal transplants might be used to treat other gut-related conditions, such as ulcerative colitis and even obesity. Some very overweight people, for example, are thought to have more of a certain type of bacteria in their intestines, which causes them to extract extra calories from complex carbohydrates. With this in mind, researchers found that fat mice would lose weight if transplanted with feces from thin ones. Later, a team of Dutch researchers tried the same approach in humans: No one lost weight, but the fecal recipients did show a significant improvement in their ability to regulate insulin. (That study is under review and should be published in the next few months.)
For all its promise, it's unlikely fecal transplants will take off any time soon. Not because patients are grossed out by the procedure—in fact, doctors say that long-standing sufferers from C. diff are eager to have it done—but because there's so little funding for large-scale clinical trials. Drug or medical-device companies usually foot the bill for such research, but in the case of a natural, patent-free treatment like this, no company stands to turn a major profit. If anything, fecal transplants would end up costing the pharmaceutical companies money: A single pill of vancomycin—one of two antibiotics used to treat C. diff—costs about $55, and the average dose is four pills daily over a two-week stretch. A glass of shit, on the other hand, costs very little. That doesn't mean we'll never get the much-needed data: Lawrence Brandt, the gastroenterologist in the Bronx, is applying for a grant with the National Institutes of Health for a small, double-blind, controlled study. He says he'll need about 40 patients, and he's hoping to get started right away.
Emily P. Walker is Washington correspondent forMedPage Today.
Electron micrograph image of c.diff bacteria by CDC Public Health Image Library.