This study by Kunde et al in JPGN was a pilot study of “faecal (poo) transplanation” for children with ulcerative colitis (UC). This is a potential treatment that has gained an increasing amount of interest within the IBD research community. Changes in the intestinal microbiota (discussed several times on this blog) have been linked in different ways to IBD, and faecal transplantation is now a well-recognised treatment for resistant Clostridium difficile (C. diff) infections. There have been previous small studies in adults with IBD but none of these has generated convincing evidence that it is an effective therapy.
There are clearly several practical difficulties in doing faecal transplantation. Kunde et al selected 10 patients with stable UC with mild-moderate disease. The patients were between 7 and 21 years old and chose their own faecal donor. The stool was processed fresh daily, mixed with warmed water, and instilled rectally as an enema of 60ml at a time, up to a maximum of 240ml, as tolerated over an hour. This was done daily for 5 days.
There were a number of mild reactions to the enemas, such as bloating, pain and diarrhoea. Two patients had fevers, and anti-fever medicines (such as paracetamol) were given to patients after the procedures. One patient could not tolerate the enemas.
The patients were followed up for 4 weeks with 6 patients reported improvement, 3 of whom were defined as being in remission.
The authors suggest that these results are reassuring with regards to the safety of this treatment in children with UC and the clinical response is encouraging. However, this is a very small study, and, as the authors themselves point out, lacks any data on the patients’ stool contents either before or after the intervention. Also, while the patients were on apparently stable medication, many were on immune modulation and/or steroids. This may have been what affected their clinical condition (rather than the transplant), but perhaps more worryingly, this would leave them immunocompromised at a time while receiving this treatment. Indeed, at the recent European Society for Paediatric Gastroenterology, Hepatology and Nutrition meeting in London, a key note talk was given by Severine Vermeire from Belgium, who stated that in a similar study in patients with Crohn’s disease she had performed, many patients developed high fevers and became unwell immediately following treatment. In my opinion we must be extremely cautious in placing what are essentially foreign bacteria in direct contact with a damaged intestinal wall, where they can presumably more easily pass in to the blood stream and cause serious infections in already unwell children.
While this study attempts to address some of the practical issues around faecal transplantation, this treatment is still a long way away from the mainstream.
Much more needs to be understood about the fundamentals of healthy and diseased peoples’ stool composition, and its interaction with the immune system.
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