Fecal transplantation for treatment of inflammatory bowel disease

Aamer Imdad; Maribeth R Nicholson; Emily E Tanner-Smith; Joseph P Zackular; Oscar G Gomez-Duarte; Dawn B Beaulieu; Sari Acra

doi:10.1002/14651858.CD012774.pub2

Stool transplantation for treatment of inflammatory bowel disease Background Ulcerative colitis (UC) and Crohn's disease (CD) are two types of inflammatory bowel disease (IBD) that lead to chronic inflammation in the digestive tract. The mechanism leading to inflammation in IBD is poorly understood, yet it is thought to involve a complex interaction between the immune system, the gut and gut microbes. New evidence suggests that the composition of gut microbes in a patient with IBD is different and possibly abnormal, and that correction of this abnormality might help control the inflammation seen in patients with UC and CD. Stool administration from healthy donors to patients with UC or CD is an intervention that seeks to restore a more healthy balance of gut microbes, and control IBD. Review question To assess the effectiveness of stool transplantation for the treatment of UC and CD. Review methods We searched multiple databases for randomized studies. A randomized study is a type of study where participants are allocated to an intervention or a control group in a random manner and is considered to be the most superior research design. We pooled data from different studies to obtain overall estimates of the effect of stool transplantation for the treatment of UC and CD. The literature search is current to 19 March 2018. Study characteristics We found four studies (277 participants) that assessed the effectiveness of stool transplantation for the treatment of adults with active UC. We did not find any randomized studies that assessed stool transplantation in participants with CD or in children. In addition, we did not find any studies that assessed maintenance of remission in participants with inactive IBD. Two of the identified studies were conducted in Australia, one in Canada, and one in the Netherlands. The dose, route, frequency, volume, type of donor, and severity of disease of recipients varied among the studies. Key results Combined results from four studies including 277 participants indicated that stool transplantation increased rates of resolution of symptoms (also termed clinical remission) of UC patients by two‐fold compared to controls. At 8 weeks after transplantation, 37% (52/140) of participants in the stool transplant group were in remission compared to 18% (24/137) of participants in the control group. Combined data from the same four studies showed similar rates of serious side effects. Seven per cent (10/140) of the stool transplantation group had a serious side effect compared to 5% (7/137) of the control group. Serious side effects included worsening of ulcerative colitis that required intravenous steroids or surgery; infections such as Clostridium difficile and cytomegalovirus, small bowel perforation, and pneumonia. The incidence of side effects were similar in both stool transplant and control groups and included abdominal pain, nausea, flatulence, bloating, upper respiratory tract infection, headaches, dizziness, and fever. Data from three included studies showed that stool transplantation helped improve UC when the assessment of disease resolution was made by the appearance of the intestinal lining when visualized with an endoscope. Quality of evidence We rated the overall quality of the evidence using the GRADE approach, which takes into account the type of studies, methodological flaws within studies, the consistency in reporting of results across studies, method of measurement of effect of intervention and statistical confidence in the summary estimates. Based on these criteria, we judged the overall quality of the evidence for most of the outcomes to be low based on a small number of events and participants and inconsistency of results. Conclusions Fecal microbiota transplantation may increase the proportion of participants achieving clinical remission in UC. However, the number of identified studies was small and the quality of evidence was low. There is uncertainty about the rate of serious side effects. Thus, no firm conclusions can be drawn regarding the benefits and harms of stool transplantation in people with active UC. We did not find any studies that addressed treatment of CD with stool transplantation or studies that assessed stool transplantation in children with IBD. In addition, we did not find any studies that assessed long‐term maintenance of remission in participants with inactive IBD. More studies are needed to enhance the knowledge about use of stool transplantation for treatment of IBD.

Fecal transplantation for treatment of inflammatory bowel disease

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