Fecal transplantation

At the university hospital in Örebro, a study is underway testing selected stool from a ‘healthy donor’ as a treatment for IBS, known as fecal transplantation. This is the first larger randomized study specifically on IBS patients treated with stool from healthy donors, as previous research has only been conducted in smaller observational studies.

The Örebro study is called ‘Fecal Microbiota Transplantation in Patients with Irritable Bowel Syndrome,’ and the research is led by Professor and Gastroenterologist Robert Brummer. Stool rich in bacteria that produce butyrate will be used in this study. Butyrate has been shown to be lacking in individuals with IBS. Several studies and treatments have previously been conducted using this method on patients with recurrent severe Clostridium difficile infections in the gut. The results have been very promising so far.

Fecal transplantation is not a new invention.

Modern gene technology has breathed new life into the ancient art of transplanting donated feces into individuals with disrupted gut flora. The use of feces as a ‘healing’ force has been part of Chinese medical culture since the 3rd century. In Western medicine, documented attempts date back to 1958. Progress has been slow. One significant reason is that the intestines and their contents have long held very low status in medical research, and interest from the pharmaceutical industry has been lukewarm since fecal transplants hardly boost the sales of medications; quite the opposite.

Research in this area is still in its infancy, but interest continues to grow. Both in Europe and the USA, extensive mapping of human gut bacteria has been underway for several years.

Our gut flora is a microbiotic organ that appears to play a significant role in our health. A changed gut flora, known as dysbiosis, is claimed to be the cause of an increasing number of diseases. Regarding treatment methods for dysbiosis, there are many opinions, but fecal transplantation is one of the more promising and simultaneously most controversial proposals.

The effectiveness of fecal transplantation for treating recurrent C. difficile infections is well documented. Studies have now also shown signs that conditions ranging from inflammatory bowel disease and high blood pressure to diabetes and obesity could be positively influenced by a changed gut flora through fecal transplantation. This could be a matter of life or death for tens of thousands of patients.

Three main groups of gut flora

One of the most striking findings so far is that every person has one of three clearly distinguishable types of gut flora. The determining factor for which main group one belongs to does not seem to depend on where one lives, which ethnic group one belongs to, what one eats, or whether one is a woman or a man.

The gut microbiota of the population can be broadly divided into three biotopes. The human gut biotopes are named after their respective dominant bacteria: Bacteroides, Prevotella, and Ruminococcus. The type of gut flora may be important, among other things, for how much of various nutrients and medications the intestines can absorb. It is also known that the gut flora affects the amounts of various vitamins produced in the intestines. This type of knowledge could lead to a new market for health food products (probiotics) tailored to your specific gut biotope.

Stool or Probiotics?

A problem with probiotics is that they only contain one or a few species of bacteria. Most of them die along the way through the digestive system. The bacteria that survive all the way down to the colon face tough competition. In the gut, there are over a thousand species of bacteria that have developed in interaction with each other and with their host organism. This means that a transplantation of a whole ecosystem introduced into the gut is likely a more effective way to change the bacterial flora.

What are we waiting for?

There are still many questions to be answered. What should the criteria be? How sick must the patient be? Should one intervene early or late in the disease course? Must the patient have prior treatment with antibiotics? Should fresh, frozen, or cultured stool be used? Should there be one or multiple donors? To what extent should the donors be screened for disease? Should the stool be administered from above or below? Must the treatment be repeated to be effective? And who should be responsible for the treatment of the ‘microbial organ’?

One problem is finding the right donor. When seeking more suitable donors to establish a bank of super donors, 95% of the applicants were disqualified. It turned out that ‘healthy people’ are rare. Before each transplantation, expensive laboratory tests are performed to see if the donor carries any infections that could spread. Swedish researchers have developed a simpler method that repeatedly uses bacteria from the same core healthy donor.

Stool from a healthy middle-aged woman in Norway was donated in 1995. Her stool has fully normal biochemical properties and is also free from bacteria such as salmonella, shigella, campylobacter, and disease-causing viruses and parasites. Probably, only a small part of the donor’s original gut flora remains in the culture. Despite this, the bacteria have a good effect. Efforts are now being made to freeze-dry the bacteria in the cultured gut flora and pack them into capsules that can be swallowed. This could solve many of the ‘aesthetic’ problems that have led doctors to prefer prescribing antibiotics rather than injecting gut bacteria from a donor into their patients.

‘If we are still doing fecal transplants in five years, we have failed.’

(Quote by well-known Icelandic gastroenterologist Eamonn Quigley)

Manipulation of the gut flora has come to stay as a treatment method. However, fecal transplantation must still be viewed as a temporary solution, and the goal is to administer the gut flora in a non-liquid form. In the long term, the aim should be to identify specific microbial dysfunctions and restore them via next-generation microbial medicines.

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By: Sofia Antonsson

Reg. Dietitian, Belly Balance