Background: Although the etiology of idiopathic ulcerative colitis (UC) remains poorly understood, the intestinal flora is suspected to play an important role. Specific, consistent abnormalities in flora composition peculiar to UC have not yet been described, however Clostridium difficile colitis has been cured by the infusion of human fecal flora into the colon. This approach may also be applicable to the treatment of UC on the basis of restoration of flora imbalances.
Goal: To observe the clinical, colonoscopic and histologic effects of human probiotic infusions (HPI) in 6 selected patients with UC.
Case Reports: Six patients (3 men and 3 women aged 25–53 years) with UC for less than 5 years were treated with HPI. All patients had suffered severe, recurrent symptoms and UC had been confirmed on colonoscopy and histology. Fecal flora donors were healthy adults who were extensively screened for parasites and bacterial pathogens. Patients were prepared with antibiotics and oral polyethylene glycol lavage. Fecal suspensions were administered as retention enemas within 10 minutes of preparation and the process repeated daily for 5 days. By 1 week post-HPI some symptoms of UC had improved. Complete reversal of symptoms was achieved in all patients by 4 months post-HPI, by which time all other UC medications had been ceased. At 1 to 13 years post-HPI and without any UC medication, there was no clinical, colonoscopic, or histologic evidence of UC in any patient.
Conclusions: Colonic infusion of donor human intestinal flora can reverse UC in selected patients. These anecdotal results support the concept of abnormal bowel flora or even a specific, albeit unidentified, bacterial pathogen causing UC.
The use of human fecal flora to treat gastrointestinal (GI) disorders is not a novel concept, having been practiced periodically for more than 40 years. 1 Bacteriotherapy utilizing human feces has been reported to achieve success where antibiotics have failed. While the best known application of bacteriotherapy is in the treatment of unresponsive Clostridium difficile diarrhea and pseudomembranous colitis, 1–10 significant clinical improvements have also been reported in other GI conditions including constipation, irritable bowel syndrome (IBS), and inflammatory bowel disease (IBD). 3,6,11–14
Although the pathogenesis of ulcerative colitis (UC) is unclear, one hypothesis attributes the etiology and persistence of the inflammatory process to the intestinal flora. 15,16 Perhaps a viral, bacterial or chemical “trigger” invokes an overly aggressive host immune response that is perpetuated by the resident flora long after the initial infection has resolved. 17–19 Loss of tolerance to the normal luminal contents caused by abnormalities in mucosal permeability or a lack of regulatory cells/mediators is also thought to give rise to chronic inflammation in genetically susceptible individuals. 20,21 Given the complex composition of the intestinal flora, it is also feasible that the chronic recurrent inflammation associated with UC is the result of a persistent infection with a specific, but as yet unidentified, pathogen. 22,23
The use of human fecal bacteriotherapy may have a role in the treatment of UC since it has consistently demonstrated efficacy against C. difficile colitis. 1–10 Furthermore, Bennet and Brinkman 11 reported prolonged remission of UC in the absence of C. difficile after the administration of a single fecal enema. With this in mind, we carried out fecal bacteriotherapy in 6 patients suffering longstanding idiopathic UC. Because human feces may be regarded as the ultimate probiotic mixture, the procedure itself was termed a human probiotic infusion (HPI). The results and long-term follow-up are compiled here as a series of 6 case reports.
From the Centre for Digestive Diseases, Sydney, Australia.
Submitted April 3, 2002.
Accepted October 15, 2002
Address correspondence and reprint requests to: Dr Thomas J. Borody, Centre for Digestive Diseases, 144 Great North Rd, Five Dock NSW 2046, Australia e-mail: email@example.com.