May 26, 2017

Fecal Transplant for Ulcerative Colitis – how many do you need to do?

How many Fecal Transplants do I need to do?

One question I have often gotten is how many Fecal Transplants do I need to do and for how long. Since until very recently very few doctors would perform the Fecal transplant procedure (also known as Fecal Microbiota Transplants, Fecal Enemas and several other names) in the U.S. we were left with a few articles from doctors. There are some person experiences which are well-documented, however it is hard to directly compare one exact case to another given the dynamic nature of this illness. There could have been from different kinds of illnesses ranging from more like c. diff Colitis to Ulcerative Colitis to Crohn’s Colitis or Crohn’s Disease. While c. diff Colitis is the most commonly treated at the moment using Stool Transplants it seems reasonable to believe this could help almost any problem where the balance of different types of bacteria in the intestines is the root cause.

For case of Colitis caused by Clostridium Difficile a few days worth or sometimes one treatment is enough for a lasting cure. For Ulcerative Colitis it could take a little longer. In Barody’s study Treatment of Ulcerative Colitis using Fecal Bacteriotherapy the patients did the fecal enemas for 5 days and then stopped and by 6 weeks later were becoming much better.

I spoke with another person who used the Fecal Transplants to help her son’s Crohn’s Colitis. It was her belief that he needed to do many more of these transplants for several months first every day and then tapering down to less and less of them each week, and that doing them for less time had not been effective in the past.

In my case I did Fecal Transplants every day for 5 weeks, yet a sustainable recovery did not occur until almost 10 days after I had stopped the FTs, and about 6 – 7 weeks after I had first started them.

Why would some people’s cases of digestive disease take longer to respond to treatment than others?

Here are several factors that could impact the time it takes:

1) What kinds of bacteria are involved as the primary trigger for the illness?
2) Where did the inflammation start and where did it spread from there?
3) How long has the illness been active?
4) How much tissue damage is there, where is it and how severe is it?
5) Average bowel transit time during the time the fecal transplants are being done.
6) Psychological stress / distress

1. What kinds of bacteria are involved as the primary trigger?
– Some forms of bacteria that cause bacteria food poisoning appear to resolve on their own over a matter of days without treatment using anti-biotics. These don’t normally cause severe inflammation.
– Other forms of bacteria are known to cause traveler’s diarrhea and are treated with anti-biotics.
– Some forms of bacteria like Clostridium Difficile are hard to treat permanently with just one course of anti-biotics, however it responds very rapidly to Fecal Transplant and in most cases it amounts to a cure where no further treatments are necessary.
– However while hardy and often resistant to anti-biotics c. diff is a relatively weak bacteria that occurs in most healthy people without incident. In most cases what triggers this is anti-biotic treatment for another illness and then overgrowth of c. diff. It isn’t until after other bacteria have been wiped out that c. diff takes over.
– Other forms of bacteria or combination of bacteria that have not been identified, but can not completely eradicated by anti-biotics. My case of Ulcerative Colitis did respond well to an anti-biotic the first time it was used, however it came back and subsequent uses were less effective. Anti-biotic resistance has been known to happen with the course of many bacterial illnesses over the years.

2. Where did the inflammation start and where did it spread?
– Is it in the rectum? descending colon? the whole thing? Is it continuous inflammation or is it patchy?
– Is it only in the small intestines or both small and large?
– Different areas could mean different kinds of bacteria that thrive in different areas. Also if is it farther up the large intestine or into the small intestine, treatments like Fecal Transplant could take more time to work.
– Another possibility is that a nasal gastric tube or colonoscope could help speed the entry of new bacteria to the small intestine since it might be difficult for the bacteria to colonize up from the large intestine.

3. How long has the illness been active?
– The longer the illness has been around the more chance for it to become resistant to anti-biotics and become stronger and different from the strain or strains of bacteria that first caused infection.
– It is possible that immune suppressing drugs, anti-biotics and dietary changes have changed the nature of the bacteria in the gut. Changing bacteria could mean changing symptoms, and some areas could get better while other areas could become inflamed for the first time.

4) How much tissue damage is there, where is it and how severe?
– A longer course of illness also means that tissue would be more badly damaged and therefore takes more work from the body to heal. In my case the surgeon who would have performed my Colostomy Once told me that tests found low albumin levels in my blood. Alumin levels measure the amount of protein available for your body to rebuild damaged tissue.

It then made sense why I was not recovering between flares and why Prednisone was not as effective as in the past. The reasons my body was not healing because it was low on resources necessary to make it happen.

Digestive illnesses in particular can be hard to heal because the illness can reduce appetite or desire to eat, or attempts to change or restrict you diet could also reduce the amount of nutrition that you get.

This at a time when the damaged tissue could also cause less nutrients to be absorbed at a time when the body needs more. More inflammation leads to less desire to eat and less ability to absorb nutrients which prolongs the amount of time it will take to heal.

– Also some parts of the digestive track may take longer to heal than others depending on where they are. Certain foods might also aggravate inflamed areas that are trying to heal as well.

5) Average bowel transit time after the fecal transplants.
– It stands to reason that it would be hard for new bacteria to expand their way up the colon when confronted with a steady stream of watery diarrhea. Its kind of like swimming upstream. However continuing to the transplants would force more bacteria in to seed its way in there which could be helpful.
– Also helpful would be ways to limit the diarrhea through diet and anti-spasmodic drugs. I believe this was the decisive factor in my case. I believe the prescription drugs I took helped slow bowel transit time which helped the new bacteria colonize and also calm muscle spasms that may have upset areas that were trying to heal from inflammation.
– I do believe it is possible that continuing to do the Fecal Transplants after the necessary bacteria have established themselves could be counterproductive in that the excess bacteria causes bloating and triggers continued unrest in the bowels which would not otherwise exist. These symptoms of gas, diarrhea and urgency could easily be mistaken for continued disease leading someone to falsely conclude they need to do more or conclude that it isn’t working.

6) Psychological stress / distress
It is relatively accepted that a person’s state of mind can have an impact on the course of any illness. Digestive diseases certainly seem to fall into this category as stressful events or depression can often trigger flares. But why and how do they impact the illness?
– Psychological stress can cause indigestion, or incomplete digestion can cause problems because undigested food can start to decompose in the digestive track.
– Stress can also weaken the immune system and / or cause more stress hormones to be released in the body. Once started it can be a tough process to break.

My case
In my case I had a relatively normal case of Ulcerative Colitis which started as left-side Colitis in the rectum, sigmoid colon and descending colon and gradually spread its way up the colon to become pan Colitis. By the time I started the fecal transplants there had been extensive inflammation throughout my entire colon for many years. This means the surface lining of the colon had been pock marred with scars from previous ulcers and there were others at various stages of formation, rupturing and also healing. While also taking longer to heal, a more damaged surface of the colon could also provide more nooks for bacteria to stay as they become embedded in the lining. This would include bacteria that can reproduce from spores after being dormant. So the ulcerated lining means that it is harder to kill all of the bacteria.

Conclusion
These factors could The illness could be some combination of both Crohn’s and Colitis or even change over time. This would explain part of the reason why different treatment approaches seem to help some of the time but not others. The good news is that if the root problem stems from bacteria if you can permanently change the bacterial content you can alter the course of the illness and stand a good chance of curing it.

Comments

  1. Hi there. Great website and full of information.

    I’m currently being treated for UC with FMT by Prof Borody in Sydney and am interested to be able to ask you a coupe of questions directly (as they related to your treatment) if you would mind sparing the time to a fellow UC sufferer.

    Cheers from Down Under

    • Hi Craig, please inform us on your progress with dr Borody. My daughter is currently on antibiotic treatment. I dont know how it will effect her later, since all doctors have concerns about antibiotics being taken for such a long time- 3 month. We still can’t find ahealthy donor. Did you go through antibiotic treatment and for how long? Diet?

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