Ryan Schneider was just 25 when he developed incapacitating chronic pelvic pain. Urologists tried and failed to identify the cause and instead, simply assumed that it was UTI or an STD, and tried treating it with antibiotics.
Ryan would wake up every morning vomiting. He also experienced severe diarrhoea, fatigue, loss of appetite, trouble sleeping and anxiety. His immune system had become as weak as that of someone with HIV, AIDS, or cancer and he lost 20 lbs pounds over the course of the year. Eventually, he had to start seeing a therapist who put him on antidepressants for the toll the illness had taken on him.
Antibiotics clearly weren’t helping Ryan – in fact, they could actively have been making his condition worse.
The microbiome – and how antibiotics can upset it
The human gut is home to trillions of microorganisms, including bacteria, viruses and fungi, that are collectively known as the gut microbiota. The word microbiome is often used in lieu of microbiota but technically refers to the genetic material of the microbes in an environment. This complex ecosystem plays a vital role in our health, helping to regulate things like digestion, nutrient absorption, immune function, and as we’ve recently discovered, even our mood and mental health.
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Given this, it isn’t difficult to see why dysbiosis, or an imbalance in the normal microbial communities that inhabit our gut, can lead to a range of problems, including inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS), but also chronic fatigue syndrome, anxiety and depression. Dysbiosis can be the result of many things, including the intake of antibiotics, which work by killing or inhibiting the growth of bacteria and are unable to distinguish between favourable and detrimental species.
For Ryan, a stool sample is what finally gave answers. His colon was infected with a bacterium called Clostridium difficile that causes symptoms similar to what he was already experiencing. C. diff impacts around half a million people every year and kills 15-30 thousand of those infected and according to the CDC, most cases of C. diff occur after an extended course of antibiotics.
This is because beneficial species of gut bacteria keep the growth of pathogens in check and antibiotic-induced dysbiosis creates the ideal environment for pathogenic species to thrive. Some antibiotics, like clindamycin and cephalosporins, are known to be more likely than others to cause C. diff infections.
Poop transplants – a potential godsend
In Ryan’s case, it’s not clear whether the C. difficile was the cause of the initial pain or an impact of the antibiotics.
A relatively novel, highly unconventional approach to treatment, however, offered hope. Sick of having had the illness compromise his quality of life for over a year, Ryan decided to undergo what’s known as a faecal microbiota transplant (FMT). This involves transplanting faecal matter – or more simply, poop – from a healthy donor into the gut of a sick patient to restore a healthy balance of gut bacteria, and when it comes to curing C. diff, FMT has remarkable success rates that go over 90%.
Dr Byron Vaughn, an associate professor of medicine and co-director of the IBD Program at the University of Minnesota in Minneapolis, is enthusiastic about FMT as a treatment for C. difficile. He calls it a “godsend” and predicts that in the next decade, FMT will transition from a third-line to a first-line therapy, and may even be used preventatively in individuals at elevated risk for C. difficile due to factors like frequent antibiotic use and advancing age.
To perform the procedure, most doctors get the faeces they need from OpenBiome, a nonprofit stool bank in Cambridge, Massachusetts. OpenBiome selects donors based on a three-stage process that only 4% of people are able to pass.
The process includes a 109-point clinical assessment that most fail, followed by a stool sample, and a blood draw. Those who qualify are given an avatar accompanied by a comic pseudonym like Albus Dumbledore, Ninja Turdle and Scooby-Doo Doo and are paid US$40 for each stool sample that they submit.
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Incoming samples are rigorously screened for infection and then processed, usually by mixing with saline and filtering to remove solids. They’re then quarantined in a freezer for 60 days before they’re ready to be administered. Most are administered directly into the recipient’s intestine during a colonoscopy done under anaesthesia. Some, however, make their way in via nasogastric tubes, enemas, or swallowable capsules.
While the idea of using poop as a medical treatment may still sound odious, its benefits, especially in the case of C. diff, are inarguably impressive. Ryan’s transplant was administered via a colonoscopy and his symptoms began to dissipate within hours of his transplant – not long after, he was able to resume living a normal life.
In addition to C. diff, FMT has also shown promise in treating conditions that don’t directly affect the gut, including metabolic syndrome, multiple sclerosis, and depression, and has the added advantage of having a low risk of side effects, provided that donors are rigorously pre-screened. However, scientists are still trying to grasp the full scale of the impact of our gut microbiome on our health and well-being and FMT’s effectiveness in treating conditions other than C. difficile isn’t as well-established.
More research is needed to determine which patients are most likely to benefit from the procedure even for conditions related to the gut. Research is underway around the potential usefulness of FMT for conditions like IBS, which involves abdominal pain and altered bowel movements, and IBD, which is a term for two conditions – Crohn’s disease and ulcerative colitis – that involve chronic inflammation of the gastrointestinal tract.
The underlying pathology for both IBS and IBD involves an abnormal immune response to gut bacteria in genetically susceptible individuals, leading to inflammation in the colon and small intestine that further alters the gut microbiome creating a vicious cycle. FMT could theoretically help break the cycle in affected individuals and restore gut health, but these chronic conditions have a more complicated relationship with gut dysbiosis than C. difficile, and this relationship isn’t yet fully understood.
The procedure, of course, does also carry some risks. If administered through a colonoscopy, there’s a chance of colon perforation and despite careful donor screening, the possibility of transmitting infections and diseases still exists. E. coli transmission through FMT isn’t unheard of and according to Sahil Khanna, a gastroenterologist at the Mayo Clinic, it is also challenging to standardise the transplant material that originates from the faecal matter of donors.
Others are uneasy about the treatment’s potential long-term risks, which, unlike short-term safety issues, remain unknown and there’s a theoretical concern that FMT may transfer a predisposition to diseases like obesity, diabetes, or metabolic syndrome since nearly every disease has been linked to the microbiome.
Despite unknowns, however, researchers and private companies remain buoyant about the treatment and are exploring the limits of its potential. Seres Therapeutics, for instance, is testing oral medications containing spores of gut bacteria to treat C. diff, ulcerative colitis, and other illnesses, while researchers at the National Cancer Institute and the NIH are exploring the potential of FMT for cancer patients that don’t respond to immunotherapy.
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The field of FMT is constantly evolving, and the prospect of novel treatments for previously chronic diseases that significantly affect the quality of life of those affected is particularly exciting. Who could’ve known that that poop could be so important?