A cheerful older woman recently walked up to the reception desk at a hospital and explained she was there for her son and his wife who were both sick with a horrible stomach bug called C. diff. The receptionist started to check if any of the hospital’s clostridium difficile patients were currently accepting visitors, but the woman interrupted: “No, I’m not here to see them,” she explained.
Rather, she was told they might benefit from a cutting-edge, highly-effective treatment — fecal microbiota transplantation. (Though like most everyone else, the woman referred to it as a “poop transplant.”) The biggest challenge, she’d heard, was finding a suitable donor, so that’s why she was there — to help her son. (Her daughter-in-law’s parents were estranged, so she was donating for both.) Then the woman reached into her purse and placed a bag of her own shit on the desk. “Could you give this to your lab people?” she requested, as though it were a set of X-rays.
This it isn’t typically how fecal microbiota transplantation goes down, but the woman was right about one thing: This shit works. Fecal microbiota transplantation is a natural, medication-free way to repopulate the human microbiome, a community of good bacteria and microorganisms living within us. And there’s a shitload of them: While the human body has about 100 trillion cells, there are 10 times as many microorganisms in your gut alone.
When the intestinal microbiome, however, becomes unbalanced — due to antibiotics or illness — it can lead to C. diff, which causes unceasing diarrhea and bloody, mucousy stools. You feel like you’re gonna die, and many do. In 2011, when C. diff was the most commonly reported infection in America, the CDC estimated it killed 29,000 people domestically and caused nearly 500,000 illnesses, more than three times the number in 2000.
Ironically, treatment for C. diff has traditionally been with antibiotics, the very thing that likely caused it in the first place. More ironic still, one in five patients has a serious adverse response to antibiotics — i.e., nausea, vomiting and intestinal hemorrhage. And so, in 2010, a gastroenterologist in Oakland named Neil Stollman pioneered fecal microbiota transplantation as an alternative. As Stollman explains in a podcast, an old friend and mentor named Dr. Chris Surawicz — considered “the godmother of American C. diff. treatment — called him and said she she had a patient in the Bay Area with horrible C. diff and begged him to do a fecal transplant on her. It took “hours and hours and hours” to get the hospital to agree to let Stollman do the procedure, he remembers, and “a million forms and consents.” (Fecal microbiota transplantation wasn’t only unconventional a decade ago, it was basically unheard of.) Eventually, though, they obliged.
Stollman went in the back to provide the sample himself and prepare the concoction since he says, “How do you ask a tech to do something like this?” He blended the stool with a normal saline/salt water solution, and using a colonoscope, pumped the mixture through the entire length of the patient’s colon. “And goddamn if it didn’t work,” he recalls.
Surawicz sent five more patients. And then 10 more. “We kind of made it up as we went,” Stollman explains. Soon thereafter at a national GI convention, he and Surawicz sat in a hotel lobby with a couple of colleagues scribbling a list of questions on bar napkins:
- How much poop do you use?
- How do you prepare the poop?
- Where do you put it?
- What do you put it in?
“This is exactly how unsophisticated science is,” Stollman says. “We sat in a hotel bar making arbitrary decisions to set up a medical protocol so other doctors could try it, too.”
In 2012, one such doctor, Allen Kamrava in L.A., called Stollman directly for a tutorial. Eventually, word spread on C. diff message boards that Kamrava was doing fecal microbiota transplantation, and before long, C. diff patients showed up at his office, pleading with him to shoot them up with shit, too. “One even broke down in tears,” Kamrava tells me. “His life had become completely unmanageable.” Like Stollman, Kamrava was shocked by the unmistakably positive results, which he calls “better than anything else you can do in surgery” and a “crazy good and effective treatment for C. diff.”
Patients soon began taking shit into their own hands. A year later, for example, Hallie, a 40-year-old California mom, found relief from seven years of unrelenting stomach pain at the bottom of her 3-year-old nephew’s Potty Froggy. Following instructions in a YouTube video, she took his stool out of the training toilet, “mushed it up” with some saline solution in a plastic baggie, and using an empty enema bottle, squirted it into her own rectum.
“Didn’t it gross you out?” people asked. No, she responded. She was desperate, and this was brown gold to her. She repeated her DIY fecal microbiota transplantation six times over the next year and made nearly a full recovery. “Now I can eat anything I want,” she says. “My quality of life dramatically improved.”
It’s impossible to know how many people, like Hallie, are robbing the Potty Froggy, so to speak, but the number of fecal microbiota transplantations is thought to have eclipsed 10,000 and climbing. Similarly, two years ago, Stollman, Kamrava and a few others were the only doctors offering fecal microbiota transplantation. Today, hundreds do.
That said, it’s hardly a novel concept. The notion of treating fecal diseases with fecal matter originated in China millennia ago. Fourth century Chinese medical literature mentions it to treat food poisoning and severe diarrhea. Twelve hundred years later, the aptly-named Li Shizhen — a Chinese physician, scientist and herbalist of the Ming dynasty — used “yellow soup” (aka “golden syrup”) that contained fresh, dry or fermented stool to treat abdominal diseases. Made of fecal matter and water, the soup was drunk by the patient.
Additionally, veterinarians have used stool as a therapeutic modality since the 17th century. In a recent study, researchers transferred fecal bacteria from one group of starving Koalas, considered nature’s fussiest eaters, to another. Within two weeks, the koalas could eat the strain of eucalyptus they were previously unable to digest.
As for human donors, Kamrava says they’re typically friends and family who have been screened (it’s not like an organ that needs to be a direct match, he says). If one’s unavailable, he orders from OpenBiome, a nonprofit stoolbank that delivers fresh feces nationwide — more than 50 specimens a week — to hospitals in 36 states. Becoming an OpenBiome stool donor isn’t easy, though. As the New York Times recently explained, volunteers who apply to be stool donors go through an intensive screening process, including an online health questionnaire followed by an hourlong clinical interview about their current health status, their health history and their family’s health history. If they pass the interview, their blood and stool undergo rigorous testing for pathogens and infectious diseases. “Only about 3 percent make it through our screening process,” says Carolyn Edelstein, OpenBiome’s executive director.
Once accepted by OpenBiome, donors make a commitment to provide three samples a week (bare minimum) at a clinical center for at least two months, earning $40 per dump. (An average-size stool can provide treatment for five individual patients according to Edelstein.)
All the while, the procedure itself is changing. These days, in fact, Kamrava no longer relies on colonoscopes. Instead, he uses scentless, tasteless fecal transplant pills (affectionately called “crapsules”), which he says are as effective as traditional FMT, but much cheaper — patients swallow 30 pills over 90 minutes at the clinic and go home. Nor is it used solely for C. diff. Kamrava notes promising results have also been found treating digestive diseases like irritable bowel syndrome, Crohn’s disease and ulcerative colitis. Other studies have shown that altering the intestinal microbiome might treat Parkinson’s disease, depression and anxiety by affecting serotonin levels, thanks to the “gut-brain axis.”
Still more research suggests that performance-enhancing probiotics found in the guts of elite athletes could be transplanted into a couch-potato’s stomach, making it as strong the Olympic marathoner he’s watching on TV. Kamrava, meanwhile, has patients who have done at-home transplants on autistic children and seen “significant improvements” in social behavior. “That tells me there are things about gut microbiome that we don’t understand,” he says. “And to me, that means we should be open to any possibility.”