AmyTuteurMD

AmyTuteurMD
Bio
Dr. Amy Tuteur is an obstetrician-gynecologist. She received her undergraduate degree from Harvard College and her medical degree from Boston University School of Medicine. Dr. Tuteur is a former clinical instructor at Harvard Medical School.

Editor’s Pick
DECEMBER 15, 2008 9:04AM

The grossest medical procedure ever!

Rate: 18 Flag

disgusted

In an ongoing effort to keep readers apprised of the latest, the most interesting, and most unusual stories in medicine, I have come across a medical procedure that fits all three criteria. In addition, this is undoubtedly the grossest medical procedure ever.

Be warned! If you are squeamish, do not read any farther. I say this with a certain amount of authority; I have spent many years immersed to the elbows in people’s internal organs, and covered in bodily fluids, but I was shocked by this. Even the name of the procedure is repulsive, but it is a real procedure that has been successful in treating a very serious problem. What is it?

Fecal transplant … (yes, it’s just what you think it is).

Before we get to the mechanics of the procedure, a digression is in order to explain the disease it is designed to treat. The problem is also unpleasant, but a serious, and growing, danger to our health. The technical name is Clostridium difficile enteritis, but is more commonly known as C. diff infection.

C. diff bacteria are everywhere in our environment, and many of us carry it in our intestines. Normally, it is kept in control by the many other forms of bacteria that reside in our gut. However, when a person takes powerful antibiotics, the majority of bacteria in the gut may be killed off. This allows the C. diff bacteria, which are hardier, to overgrow and produce large amounts of a toxin that inflames the intestines. In effect, this is similar to what happens to many women when they take antibiotics and end up with a yeast infection. The antibiotics kill the normal bacteria of the genital tract, allowing the yeast to take over and cause an infection. Yeast infections, while very unpleasant, are usually not dangerous. C. diff, on the other hand, can be very serious.

Some cases of C. diff infection are mild, causing diarrhea and abdominal cramping. But new strains of C. diff are emerging that produce more powerful toxins and can cause severe, even deadly illness. A severe infection with C. diff can lead to profuse diarrhea, severe abdominal pain, fever and debilitating illness. That’s what happened to Vicki Doriot, profiled in and MSNBC article about the new procedure:

“When those toxins are in your body, you kind of feel like you’re close to death,” said Doriott, 52, an accountant from Eau Claire, Wis., who spent nearly six months battling recurrent bouts of the nasty intestinal bug known as C. diff…

“At its worst, I’d have diarrhea every 15 minutes,” recalled Doriott. “I’d be going for two or three days. I’d have a 103-degree fever. I couldn’t make it two steps from the couch.”

C. diff is caused by powerful antibiotics, but it can be cure by other, equally powerful antibiotics. Unfortunately, a new dimension of C. diff disease has emerged: drug resistant C. diff. Up to 20% of new case of C. diff illness are caused by drug resistant bacteria. There has been some success in treating drug resistant C. diff by using newer antibiotics, but there remain some patients who cannot be cured with antibiotics.

Since C. diff infection is invariably the result of antibiotic treatment that destroys the normal bacteria of the intestines, some scientists and doctors have reasoned that restoring the normal bacteria could allow the body to heal itself. Yet it is not as simple as isolating one or two different kinds of bacteria to use for replacement. It is the complex interaction and interrelationship between many different kinds of bacteria that prevents the overgrowth of C. diff. And where can you find a combination of the right bacteria in just the right proportions? You guessed it … in the gut of someone who does not have a C. diff infection.

That’s how they hit upon the idea of a “fecal transplant.” Not surprisingly, only those patients who are desperately ill are willing to try fecal transplant. That’s what happened to Doriott:

After months of exhaustion and illness, Doriott became desperate enough to consider the fecal transplants she’d heard about through research…

Typically, patients ask a close household member, usually a spouse, to produce a sample of stool, which is tested for disease and infection. In Doriott's case, her husband, Jerry, 50, a civil engineer, was on tap.

On the day of the transplant, donors provide the feces, which is blended and filtered. A tube is fed through the patient’s nose into the stomach and several teaspoons of the sample are injected through it.

“I refused to look at it,” said Doriott. “All I felt was a coolness. It didn’t smell.”

Doriott said she felt better immediately and hasn’t suffered a C. diff relapse since the treatment…

There have been enough patients willing to undergo the procedure that a formal study has been published:

A 2003 case study of 18 patients who received fecal transplants found that two patients who were very ill died shortly after transplant. But of the remaining 16 patients, only one developed C. diff again, according to the study published in the Journal of Clinical Infectious Diseases.

The use of fecal transplant is reminiscent in some ways to the early treatment of other serious illness. Before insulin was identified as the missing component in diabetes, scientists showed that an extract from ground up pancreas was able to cure diabetes in dogs. Eventually, insulin was isolated from the extract, and that became the standard treatment.

Ultimately, doctors and scientists will probably be able to determine the most important intestinal bacteria that need to be replaced in order to treat C. diff infection, and fecal transplant will be replaced by biotherapy with bacteria grown in sterile culture. Until then, though, this primitive form of biotherapy will have to do. It may be gross, but it is a literally life saving therapy, based on sound biologic reasoning, that allows a body to ultimately heal itself.

 

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Mind blowing. Can frequent use of laxatives contribute to this at all?
This is one of the mmost educative posts I've read.
Jason D. Hill:

"Can frequent use of laxatives contribute to this at all?"

Do you mean can laxative predispose someone to C. diff infection? As far as I know, laxatives don't have an impact. The three major risk factors are use of powerful antibiotics, age over 60, and hospitalization.
Nice post!

I recently received an email from a physician I work with describing the use of nasojejunal tube for this treatment. We had both heard of fecal transplants for C. diff, but had never considered that it would probably be delivered via a nasal tube. (The email was entitled, "Would a Tic Tac kill you?")

Although the treatment may well be considered repugnant, it promises hope for a serious intestinal infection that has few effective remedies.

This topic provides an interesting dovetail involving other research of intestinal bacteria, such as bacteria similarities in family and social groups, and common bacteria characteristics in obesity. By some estimates our bodies contain ten times more bacteria than human cells. By weight, that works out to somewhere between two and nine pounds of bacteria accompanying each of us on our daily travels.

My little buddies!
The paragraph that began "On the day of the transplant..." made me retaste my morning coffee.

This procedure was part of a recent episode of Grey's Anatomy. In that episode, a patient who was a hypochondriac took too many antibiotics killing all of the "good" bacteria in her intestines. Apparently she thought she had stomach cancer or something. Her husband refused to be the donor until she admitted her self diagnosis was wrong. He actually said "no poop for you!"

At the time, this procedure sounded completely far-fetched and made-up. Apparently, it's real. Good stuff Dr. Amy.
Yikes! I've never heard of such a thing! Couldn't the bacteria be re-colonized within the gut through use of probiotics (if it had the proper bacterium in it?) This sounds so archaic.
C. diff *shudder* I can even smell it as I type.
This is fascinating. I got C Diff several years ago as a result of antibiotic treatment for severe food poisoning. Fortunately, Vancomycin (sp?), which my Dr. called the "antibiotic of last resort", cleared it up.
Fecal infusion is a classic example of a treatment that is shown to have a high rate of success, but is not widely used because of stubbornness and conformity in the medical community.

A few points missing from Dr. Tuteur's article:

- Fecal infusion is also done via enema
- Besides its use a treatment for Clostridium Difficile, fecal infusion is also used for Irritable Bowel Syndrome (IBS), and ulcerative colitis.

A modern pioneer of this treatment is Dr. Thomas Borody of Sydney, Australia: Center for Digestive Diseases, Probiotic Therapy Research Center. With little acknowledgment from the medical community, Dr. Borody and his staff continue to pursue this and other innovative treatments. Note, however, that several papers on fecal infusion have been published in mainstream medical journals. Journal of Clinical Gastroenterology Abstract.

Additionally, you can watch a news report from Canadian Broadcasting Corp on the subject (video link in the right column).

As for the grossness factor--please get over it. Once one has suffered with a serious gastrointestinal disorder, the promise of an effective treatment for it overrides any disgust one might have with the procedure. Besides, are organ transplants, radiation therapy, or stomach stapling really any less disgusting?
@Lisa Kern:

Certainly it's worth trying probiotics, i.e., Floragen, Acidophilus, etc. before a fecal infusion. However, for stubborn illnesses, fecal infusion is far more effective than anything that comes in a pill or yogurt. The theory is that the GI system has literally millions of different bacteria, and it is this mix, not a few isolated strains, that can shift the balance of a fecal infusion recipient's GI system towards normalcy.
Sounds typical of the American Medical Establishment to me! Dangerous, unnecessary, expensive procedures, tests, surgeries, most of which accomplish nothing, but are embarassing and humiliating in addition to the risk and expense. The AME always favors over-the-top, extreme, dramatic procedures.....which is why I prefer homeopathy, herbal medicine, and TCM, all of which are not only far, far, far more effective, dirt cheap compared to the AME, neither invasive, humiliating, nor embarrassing, and do not require nudity, probing with fingers and instruments, the taking of blood and other body fluids, etc.....and what does the AME usually conclude, anyway? "We aren't sure.....let's do more tests....or exploratory surgery...or prescribe pharmaceuticals we're not sure will even help...." If anything verifies the stupidity of brainwashed Americans, it's the American Medical Establishment!!! It's my hope that one of the outcomes of the recession/depression will be the death of the American Medical Establishment, to be replaced with REAL treatments, rather than profit-oriented "medical" (not health!) procedures.
Oh, my God! It's almost analogous to the bovine forestomach version I once blogged about. Makes medical sense, but ew.
Interesting article--surprised House hasn't subjected one of its patients to this yet..

@john m
How is this an appropriate treatment for ibs? So far bacteria hasn't been meaningfully connected to the disorder; instead all signs point to a disconnect in the enteric nervous system.

And yes, organ transplants are way less disgusting than feces.
Ew! Positively gross! Although I think this is tied for first with the necrotic tissue eating maggots and abscess drainage for "grossest medical procedure ever."
But Dr. House has. Did it abut 2 weeks ago. I don't remember what the person had but that was the treatment.
Interesting post, but I am with john m. This doesn't sound any grosser than other medical procedures. As the article stated, the feces are blended, filtered and oderless. It sounds like getting a saline solution drip or something similar.

And I have had gastric bypass and iron infusion, close family members had organ transplant and radiation/chemo therapy. Fecal transplant doesn't seem any weirder than these to me.
Scott T:

"I got C Diff several years ago as a result of antibiotic treatment for severe food poisoning. Fortunately, Vancomycin (sp?), which my Dr. called the "antibiotic of last resort", cleared it up."

Yes, vancomycin was traditionally considered the antibiotic of last resort and used to cure just about everyone. Now, unfortunately, some strains of C. diff are resistant to vanco.
john m:

"Fecal infusion is a classic example of a treatment that is shown to have a high rate of success, but is not widely used because of stubbornness and conformity in the medical community."

That's absurd. This is a treatment of last resort because of the high potential for infection with viruses like hepatitis or even HIV.

No one trying to keep this secret or discouraging its use. It has been advocated in medical journals and it was just publicized on MSNBC.

"which is why I prefer homeopathy, herbal medicine, and TCM, all of which are not only far, far, far more effective"

They are not effective at all, just quackery pure and simple.
Lisa Kern:

"Couldn't the bacteria be re-colonized within the gut through use of probiotics (if it had the proper bacterium in it?)"

That's probably what will ultimately happen, but there are a lot of technical issues to resolve in order to make it possible. First, the exact types of bacteria must be identified, then they must be isolated, and then grown in culture. Second, it is unclear whether the necessary bacteria can survive outside the gut for very long, and whether they can be "packaged" in such a way that people could treat themselves. Finally, an adequate delivery system must be created. The bacteria must be delivered into the intestine, but stomach acid will kill the bacteria. The bacteria will need to be encapsulated within a covering that will not dissolve in the stomach and only dissolve in the intestine.
An elderly friend of mine contracted C. diff in the hospital earlier this year. His immune system was severely weakened by chemo (he also contracted a couple of staph infections that nearly killed him). Either the C. diff hasn't entirely gone away, or he is contracting it repeatedly; I suspect the former.

His lymphoma is in remission, and I don't think he's going to take the remaining two or three chemo treatments that were originally scheduled, because every time he's taken the chemo, he's nearly died from staph or C. diff or a combination of the two.

From what I've seen my friend go through, my guess is that probiotics wouldn't begin to touch C. diff.
Thanks for posting about C. diff infection. I thought that I had a bug (technically I guess that I do). I've been on and off antibiotics for nearly a year and they are wrecking my immune system in ways even I never dreamed of. I used to be a fire fighter/medic and do ample research when I'm ill to make sure that everything is going as it should.
Wow. Eat "s" and LIVE!
What a crappy procedure!
so... how do they choose donors?
I don't know. I don't find it all that gross. Frankly once you've had a gastro-intestinal condition, you're probably used to having your bowels probed mercilessly by every instrument and gloved hands around, and used to collecting your own bowel movements for assays and tests. It's amazing how easily you can get de-sensitized after a few weeks of this.
LuluandPhoebe:

"btw, do probiotics and yogurt (like Greek yogurt) actually help with a yeast issue or is that a myth too?"

The results have been mixed so far, but there is probably no harm in trying them.

According to Probiotics for prevention of recurrent vulvovaginal candidiasis: a review:

"...the available evidence for the use of probiotics for prevention of recurrent vulvo-vaginal candidiasis (VVC )is limited. However, the empirical use of probiotics may be considered in women with frequent recurrence of VVC (more than three episodes per year), especially for those who have adverse effects from or contraindications for the use of antifungal agents, since adverse effects of probiotics are very rare. In any case women should be clearly informed about the unproven usefulness of probiotics for this purpose. In conclusion, despite the promising results of some studies, further research is needed to prove the effectiveness of probiotics in preventing the recurrences of VVC and to allow their wide use for this indication."
susanmihalic:

"From what I've seen my friend go through, my guess is that probiotics wouldn't begin to touch C. diff. "

I don't know if it would work, but I suspect that the primary concern would be that with his weakened immune system, he would contract another disease from the transplant.
"how do they choose donors?"

The recipient chooses the donor.
I ended up with a c dif infection a year and a half ago after taking an antibiotic for an sinus infection (I have ulcerative colitis so am probably more susceptible). Although vancomycin seemed to work, after tapering off/"pulsing", the c dif came back with a vengance. I went back on the vancomycin and also started another new antibiotic called xifaxin. This, combined with a probiotic yeast strain and another strong probiotic called (900 billion organisms daily), I finally got rid of it.

I did a reasonable amount of reading at the time, and if the antibiotics didn't finally do the trick, I would have been very happy to do the fecal transplant. By the way, in the reading I did ( I believe it was the study of 18 patients mentioned) it was my understanding that the transplant was done rectally.
Somehow I knew you were going to choose the fecal transplant. But I wouldn't say it's the only horse on the track. How about using maggots to debride wounds? Leeches to drain blood? The specific mechanics of the male to female sex change? Digging out a fecal impaction?
Do they sedate you before stuffing someone's poop down your nose?
You warned me, I still read it, but DAMN - was there really any reason to post this other than attention? Are we talking epidemic here?
Yablonowitz:

"Do they sedate you before stuffing someone's poop down your nose?"

No, there's no need. It goes down a tube threaded through your nose and into the intestine.
I think it needs a more user-friendly name, like "gastrobacterial implantation" or something. Anyway, thanks - this was interesting - for the non-squeamish, at least.
It's kind of hard to resist seeing humor in this.

Regarding the woman who had the disease for six months, she says, “At its worst, I’d have diarrhea every 15 minutes,” recalled Doriott. “I’d be going for two or three days. I’d have a 103-degree fever. I couldn’t make it two steps from the couch.”

I would have hated to clean that couch and the two steps around it after 3 days of crapping.

Also, we just need to let the pharmaceutical marketers get at this. They can add aromas, flavors, myabe even shapes for the kids...New Formula! Flintstones Feces!
I'm probably no good as a sperm donor because of my rather unimpressive genetic material... but hey- I'm still good for fecal donation, right? Where do I sign up?
Jesse Lee - That's IT! "Dino Dungs!" (Of course, in the case of the brontosaurus, that would be spore of quite some considerable heft...) ((Sorry, Maxine.)
Apparently humans aren't alone in this method of stabilizing digestion. I heard about a form of this a few months ago when a wild baby bunny turned up on our doorstep and would not go away. We dutifully fed it the replacement milk used for abandoned kittens and tried to find a shelter that would take it. We gave it a few blades of grass, only to find an animal sanctuary where they told us the babies can't eat grass until they eat the waste from the mother bunny to introduce the right bacteria into their stomachs. The baby died before we could get it to the sanctuary. Whether it was from the grass or just the stress of captivity we don't know. But this story reminded me of my reaction then...at first it seemed gross, then it just reminded how removed we are from the natural world.
I'm curious if this procedure is effective for autoimmune disorders. I tend to have intestinal involvement with my Behcet's (anywhere there are small blood vessels, woohoo!) and my neighbor suffers from Crohn's. Humira works for her but I cannot tolerate any TNF suppressants. Also, I currently take doxycycline, 100 mg twice a day as Behcet's treatment though it seems to have stopped working. Will that make me more susceptible to something like this infection? Curiouser and curiouser.
Important post, Amy. Gross but necessary for some. On a lighter note, my husband thinks his shit doesn't stink so I've got my donor in the wings, just in case. Sorry, couldn't resist that.
pretend_farmer:

"I'm curious if this procedure is effective for autoimmune disorders. "

Probably not. I suspect that it will only work in situations where most of the normal bacteria of the intestine have been killed off by antibiotics. In Behcet's disease the problem is usually at the level of the blood vessels beneath the lining of the intestines, not on the surface.
"drug resistant C. diff." It's actually quite unsettling to see how many drug resistant germs are out there now, not the least of which are TB, HIV and MRSA.
Bob Conner:

"It's actually quite unsettling to see how many drug resistant germs are out there now, not the least of which are TB, HIV and MRSA."

Interestingly, each is drug resistant for a different reason.

HIV is a virus, and is unaffected by antibiotics. It is susceptible to a specific class of anti-viral drugs.

TB has become drug resistant over many years. It must always be treated with antibiotics and the best way to prevent resistance is to treat it aggressively with a multi-drug regimen.

Staph aureus is everywhere an may become drug resistant by inadvertent exposure to antibiotics. Minimizing antibiotic exposure might have delayed the appearance of MRSA.
I had H. Pylori bacterial infection in my stomach. It was the most painful thing I have ever had. I went to a chiropracter , because of the pain it caused. I thought I had a slipped disc;it hurt so bad. I would collapse on the floor when it inflamed at it's whim. I went to 5 different specialists, who all said different things: ulcer, gallstones,pancreatic issues,slipped disc,etc. Finally, I went to an 80 yr. old G.P. when it hurt so bad I was crying. He took a blood test ,and said I had H. Pylori inflammation. I took a pack of antibiotics (it's tough to kill ,too) for about 10 days, and was cured. After years and years, literally, of extreme pain. So much for the specialists.
>>"Fecal infusion is a classic example of a treatment that is shown to have a high rate of success, but is not widely used because of stubbornness and conformity in the medical community."

"That's absurd. This is a treatment of last resort because of the high potential for infection with viruses like hepatitis or even HIV."

Donors are thoroughly screened for every viral and bacterial infection under the sun (just as I expect organ and blood donors are). Donors may be friends or family members. At the Probiotic Therapy Research Center, multiple donors have been used to maximize the mix of beneficial bacteria.

"No one trying to keep this secret or discouraging its use. It has been advocated in medical journals and it was just publicized on MSNBC."

It's an open secret. Many general practitioners and GI doctors are unaware it exists. The Canadian Broadcasting Corp reports demonstrate the level of resistance to this treatment. Another factor limiting research on the treatment is that it is not a drug that can be monetized. No pharmaceutical company will develop a blockbuster drug from this research, since the source of the treatment is donor feces.

>>"which is why I prefer homeopathy, herbal medicine, and TCM, all of which are not only far, far, far more effective"

"They are not effective at all, just quackery pure and simple."

Traditional Chinese Medicine has been shown to be effective for some conditions. It is inaccurate to say that it is quackery. Read "Integrative Medicine", Dr. David Rakel, Editor.
I dunno; it definitely sounds gross, but it doesn't give me the willy-wags quite like the concept of (forgive me if this is the wrong term) "medical maggots." I mean, keeping those creatures in your body for days at a time? [shudder]
Way too much information for a saturday morning.
I'm with the reader who mentioned absess drainage. It's hard when it is someone you love. Hubby has five that he is trying to recover from. He is surviving. I've lost my appetite for the next decade and I'm not being ugly as he is really sick. I just don't know how the nurses do this. Apparently a subjective "smell" factor is also something they document.
I knew about this already. Comes of actually reading the small print of the pharmacy info on Cipro.

What I'm curious about is this: there's been some recent research which indicates differing populations of intestinal flora may be partly responsible for some cases of obesity. So... shouldn't it theoretically be possible to kill and reseed the flora using this technique?
Well I think you're full of shit.
A great, back-upable threat to a kid who doesn't live right. "If you do this . . . you'll get sick, you'll have to take anti-biotics (again), and the next thing you know . . . " Perfect. Now let's come up with something that will stop MDs from over-prescribing anti-biotics, to begin with.
Would that a fecal transplant could have treated the Crohn's I've had since I was little.
I'm w/those who say, "yawn"
I'd go for the transplant in a wink if it'd fix the intestines I was born with... Doesn't gross me out -- not with a body where getting an ileostomy would be a big upgrade in my quality of life. ;o)