“The idea of a fecal transplant is certainly strange,” admits Rick Dallaway, recalling the moment he was invited to participate in a clinical trial.
The 50-year-old man has just completed a two-month program of weekly fecal transplants at the University of Birmingham in hopes of controlling the symptoms of a rare chronic liver disease called primary sclerosing cholangitis (PSC).
“It’s not just a piece of poop,” he laughs as he explains the transplant process. “It’s treated, it’s in a lab.”
There is currently no cure for Dallaway’s rare disease, other than a liver transplant at the end of the disease. It affects between six and seven in every 100,000 people in the UK and shortens life expectancy by 17 to 20 years.
Dallaway was diagnosed eight years ago, when he was 42.
“I was feeling very anxious, very worried about the future,” he recalls. “It was like falling off a cliff.”
What is a fecal transplant?
Fecal microbiota transplantation (FMT), colloquially called stool transplant, is used in several countries for patients with intestinal diseases, mainly as part of clinical trials.
Healthy stool donors are screened and intestinal bacteria are extracted from their samples and transplanted into the patient’s intestine, usually by colonoscopy, enema or nasogastric tube.
Although Rick agreed to this transplant to treat his primary sclerosing cholangitis, in the UK it is formally recommended only for patients with a severe infection with Clostridium difficile (C. diff)which is a harmful bacteria that can cause diarrhea and usually affects people who have taken antibiotics for long periods.
A 50ml sample of liquid FMT currently costs about $1,700, which experts say is less than the cost of antibiotics and hospital treatment. For some conditions, FMT only needs to be administered once.
Some centers also offer oral capsules made from healthy bacteria found in human poop.
Fecal matter
People who need a new liver, kidney or heart can wait months or even years to find a suitable donor.
Unlike these much-needed organs, human feces are widely available, although the idea of receiving someone else’s poop may make some people uncomfortable.
But Dallaway believes in science despite the oddity. His wife and friends have been supportive of his quest.
“There’s no shame or dismay,” Dallaway says. “‘If there’s a chance it could work, why not?’ That’s the reaction I got from friends and family.”
The University of Birmingham’s Microbiome Therapy Centre (MTC) was the first third-party FMT service in the UK to provide stool samples to clinicians to safely treat hundreds of patients with C. difficile infections and conduct research trials.
At the center, donors undergo a strict screening process that includes a detailed medical history, a lifestyle assessment, and testing for pathogens in their blood and stool.
Once thoroughly analysed, healthy stool samples are stored for up to 12 months in a -80°C freezer. When a patient needs a faecal transplant, the frozen filtered stool is thawed and drawn into a syringe.
“It’s difficult in countries without stool banks, but the recommendation would be to use frozen FMT to allow time to properly screen these people,” Professor Tariq Iqbal, director of the Microbiome Treatment Centre, told the BBC.
It’s not the first option yet
Experts warn that 70% to 80% of patients with the same condition as Dallaway, PSC, will also develop inflammatory bowel disease (IBD), a term used to describe Crohn’s disease and ulcerative colitis, which can cause severe stomach pain and diarrhea.
Dr. Palak Trivedi, a hepatologist and gastroenterologist leading the Dallaway trial, says scientists don’t know why PSC develops or why it’s related to IBD.
“Our aim is to transfer a healthy composition of intestinal microbiota to the intestine of patients with CEP and see how it affects their liver disease,” explains the professor.
At the moment, fecal transplant is not the first therapeutic option offered for any condition, says Horace Williams, a gastroenterologist at Imperial College London who has helped develop formal guidelines on such transplants.
He stresses that in countries such as the United Kingdom it is only offered for severe infections by Clostridium difficile (C. diff)not for other conditions, and suggests that patients who wish to undergo the treatment for other reasons participate in clinical trials, as Dallaway has done.
Benjamin Mullish, a gastroenterologist at Imperial College London and lead author of the British Society of Gastroenterology (BSG) guidelines on FMT, told the BBC that many people perform the transplant themselves, which can be incredibly dangerous.
Medical bioethicist Harriet Etheredge points out that without experienced professionals and clear guidelines, FMT can be harmful, “especially in poorer countries where health resources are scarce.”
The treatment has even caused deaths in very rare cases.
From a family member or poop from a stranger?
In addition to the US and Europe, FMT trials have been conducted in countries such as Brazil, South Africa and India.
Some patients have been reluctant to accept treatment due to their disgust with feces, as well as various cultural, social and religious beliefs.
“People sometimes react very uncomfortably to this treatment and may think the doctor is joking or not serious,” says Dr. Piyush Ranjan, of the Institute of Liver Gastroenterology and Pancreatic Biliary Sciences at Sir Ganga Ram Hospital in India.
Speaking from personal experience, Ranjan says some patients are “more okay” with accepting stool from family members than from a complete stranger, even if the stranger has been screened and is healthy.
In contrast, a survey of more than 200 Crohn’s and Colitis UK members found that most preferred stool from an unknown, tested source to that from someone they knew.
In the same survey, 37% of respondents initially said they would not accept a fecal transplant, but after learning more about the process, this figure rose to 54%.
“Education always breaks down a lot of barriers,” Dr Bret Palmer, who led the study, told the BBC.
Dallaway now hopes his trial will lead to a cure for his rare disease.
“If someone had told me 10 years ago that human feces could treat diseases, I wouldn’t have believed it at all,” he says. “But now it’s a reality and it’s happening.”
Keep reading:
* Why there may be blood in the stool
* What do your stools reveal about your health?
* How poop can reveal secrets about your health and even your spending power
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