The Healing Power of Poop
The surprising effectiveness of poop for treating a dangerous colon infection
Dr. Larry Istrail is a physician, entrepreneur, and author of The POCUS Manifesto: Expanding the limits of our physical exam with point-of-care ultrasound. You can buy it on Amazon here.
Poop. Feces. Scat. Sh&t. Crap. #2. This revolting excrement binds all of humanity, yet most of us can’t discuss it without blushing. Its wretched smell and vile appearance do not scream ‘miracle cure’ to most. Yet, like a diamond buried deep in the Earth’s mantle, hiding in this festering log of buoyant waste is a golden ticket for those afflicted with recurrent Clostridium difficile (C. diff) colitis.
The idea that poop has medicinal properties is not new. Dr. Ge Hong in the Eastern Jin Dynasty of China about 1700 years ago was known for his feces-laden “yellow soup” concoction to treat food poisoning and severe diarrhea. The Bedouins of North Africa recommended the consumption of fresh, warm camel feces as a remedy for bacterial dysentery, a lesson German soldiers learned during World War II. After dying of dysentery by the 100s, the Germans sent in scientists to figure out why. They were surprised to find the sick locals following around camels and eating their “fresh camel apple,” reportedly resulting in restored health by the next day. When questioned about their practice, they explained it was knowledge passed down for generations, and that for it to work, you needed a fresh sample. This led to the discovery that Bacillus subtilis was responsible for their improvement. It turns out B. subtilis was only present in warm dung and would die out when the dung was cooled. By ingesting the camel dung, the nomads were altering their microbiome with this bacterial species that wards off other microbes causing dysentery.
Not wanting their soldiers to ingest fresh camel dung, they cultured large amounts of Bacilis subtilis in vats and stopped the dysentery outbreaks by feeding soldiers broth infused with it. But it wasn’t until 1958 when such a strange concept made it into the English medical literature when a team of surgeons from Colorado cured four patients who were critically ill with pseudomembranous colitis (before they knew it was caused by C Diff). Within a few hours of a fecal enema, their symptoms resolved. It took another 20 years before scientists figured out it was caused by an overgrowth of C. diff and the toxins it secreted.
C. diff is one of the 300-500 species of bacteria in your gut that together outnumber our human cells 10 to 1, which makes you wonder who’s really in charge here. They lead a happy, dark-and-damp coexistence until an antibiotic bomb is dropped, making them innocent bystanders to the cold-blooded antibiotical execution of harmful bacteria elsewhere. This in turn prevents the metabolism of cholate which then facilitates C. diff germination and overgrowth. These newly unrestrained bugs are now free to emit toxins causing colonic damage, severe diarrhea, or if left untreated, even death.
In the modern era, it is detected with a nucleic acid amplification test (NAAT) for the C. diff toxin gene, or a positive stool test for C. diff toxin itself. Contrary to popular belief, it cannot, on the other hand, be accurately detected by a human nose.
“Mr. Smith has diarrhea, and it smells C diffy” is a common call one receives when working in hospital medicine. Yet despite the frequency of these phone calls, a human superpower to detect this particular malodor appears to be grounded in fiction. In a small study comically titled What the Nose Knows Not, 18 nurses were recruited to test this hypothesis. With blinded samples, the nurses were asked to smell each one and diagnose C. diff on scent alone. Despite 11 of the 18 nurses being “confident in their sniffing abilities,” they did not do better than chance alone. A cute 2-year-old beagle, on the other hand, can detect it quite well, while other dogs had mixed results.
Fecal microbiota transplants (FMTs)
As of 2016, C Diff was the most common healthcare-associated infection, one that can be effectively treated with various antibiotics such as metronidazole, oral vancomycin, or fidaxomicin. For the initial infection, these are often curative, though the problem with antibiotics is around 20% relapse. In these patients, different antibiotics or more aggressive treatment courses are chosen, but often these fail as well. This leaves the patient with a few options: persistent severe diarrhea, death, or fecal transplant.
By the early 1980s, the scientific community knew that this ‘pseudomenbranous colitis’ was caused by the overgrowth of C. diff, and that consuming antibiotics was a significant risk factor, but the data on FMTs was slim. The first documented case of confirmed C. diff treated with a stool transplant was in 1983, in a 65-year-old woman who had “prompt and complete normalization of bowel function” that persisted at a nine-month follow-up.
A case series of 15 patients out of Oakland, California found similarly promising results. 10 of the 15 subjects received stool from their partners via colonoscopy and all of them were C. diff and diarrhea free up to 5 years out. While a diamond engagement ring from your husband “is forever,” this study showed that a stool donation from your significant other is priceless.
In another case series of 18 patients from 2003, a nasogastric tube was used in place of colonoscopy, and “[t]wenty-five milliliters of the transplant stool suspension was drawn up in a syringe and instilled into the stomach.” As repulsive as this sounds, the “patients were uniformly receptive to the prospect of stool transplantation” and ‘none of the patients in this series raised objections to the proposed stool transplantation procedure on the basis that it “lacked aesthetic appeal.”’
Going further up the ladder of miraculously-effective-yet-taboo treatment options are DIY home fecal transplants which included the following instructions from another study:
Equipment needed: (1) bottle of normal saline … (2) standard 2-quart enema bag kit … and (3) standard kitchen blender (1 L capacity) with markings for volume on side, available at any department store.
Add 50 mL of stool (volume occupied by solid stool) from donor obtained immediately prior to administration (less than 30 minutes) to 200 mL normal saline in the blender.
Mix in the blender until liquefied to “milkshake” consistency.
Pour mixture (approximately 250 mL) into the enema bag.
Administer enema to patient using instructions provided with enema bag kit. Patient should hold the infusate as long as possible and lie still as long as possible on his or her left side so that the urge to defecate is prevented. Ideally, perform the procedure after the first bowel movement of the day (usually in the morning).
Despite some of these patients having diarrhea for nearly 2 years, all seven transplants were successful and there was no recurrence up to 14 months out. Truly amazing results.
These findings have largely held up even in blinded placebo-controlled trials. For example, one study of 72 patients randomized to fresh, frozen, or freeze-dried samples found that 100% (25/25) of patients receiving the fresh sample were cured, compared to 20/24 patients who received the frozen, and 16 out of 23 that received the freeze-dried version. A small study, but consistent with the case series above as well as a meta-analysis of 8 randomized trials, concluding that:
“the use of fresh feces for bacterial transplantation was the best efficiency for [recurrent C. diff infection] compared to antibiotic therapy or placebo. The fecal transmission method by enema was not ideal, but capsules or frozen feces transported by colonoscopy could be an alternative treatment compared to fresh FMT. For patients with severe [recurrent C. diff infection], multiple fecal transplants can effectively improve their diarrhea remission rate.”
It seems the Bedouins were onto something with their farm-to-table approach.
Stool Donation
On the surface, stool donation seems a lot easier than sperm or egg. The Washington Post claimed you could make $13,000 a year donating it, which is a click-bait headline to describe a far from glamorous, seemingly full-time pooper position:
“And yes, they pay for healthy poop: $40 a sample, with a $50 bonus if you come in five days a week. That's $250 for a week of donations, or $13,000 a year.”
Fortunately, you still would have the weekends off. This is through a non-profit called OpenBiome, which is no longer accepting stool donations. But you can become a “poop with a purpose” stool donor here where they claim you can earn up to $1,500 a month. If you qualify as a donor, that is.
"It's harder to become a donor than it is to get into MIT," joked OpenBiome co-founder Mark Smith, though there is some truth to this. A New England Journal of Medicine correspondence characterized the reasons for exclusion and calculated the eligibility rates from OpenBiome, which was done in 4 stages:
Stage 1: Donors complete online prescreening to survey for general health and risk of infectious disease. Obesity (BMI over 30) and active smoking were exclusion criteria because “they are associated with perturbations in the gut microbiome.”
Stage 2: Eligible donors fill out 200-item questionnaire followed by an in-person evaluation “to exclude risk factors for transmissible diseases and potential microbiome-mediated conditions” such as “gastrointestinal, autoimmune, atopic, allergic, metabolic, neurologic, and psychiatric conditions that have been associated with an abnormal intestinal microbiome profile.”
Stage 3: Those that advanced past stage 2 undergo stool and nasal screening for various antibiotic-resistant organisms such as carbapenem-resistant Enterobacteriaceae (CRE), extended-spectrum beta-lactamase–producing (ESBL) organisms, and methicillin-resistant Staphylococcus aureus (MRSA).
Stage 4: The final stage involves blood tests screening for various infectious diseases.
From February 2014 through April 2018 15,317 candidates applied but only 386 of them made it through the screening gauntlet, computing a mere 3% acceptance rate. OpenBiome then provides these samples to hospitals and clinicians that need them, providing an aggressively un-sexy yet enormously valuable resource to patients in need.
Dr. Larry Istrail is a physician, entrepreneur, and author of The POCUS Manifesto: Expanding the limits of our physical exam with point-of-care ultrasound. You can buy it on Amazon here.