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Fecal transplant improves refractory IBS with abdominal bloating
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WASHINGTON — Fecal microbiota transplantation improved symptoms in patients with refractory irritable bowel syndrome with severe abdominal bloating, according to research presented here.
“This is one of the first ... randomized controlled trials looking into fecal microbiota transplantation (FMT) in patients with irritable bowel syndrome and predominant abdominal bloating, and our results suggest that this is a very effective treatment for these patients,” Tom Holvoet, MD, of Ghent University Hospital in Belgium, said during his presentation.
Between December 2015 and September 2017, Holvoet and colleagues randomly assigned 43 patients with refractory IBS symptoms and predominant abdominal bloating to undergo FMT via nasojejunal tube using fresh stool from two selected donors, and 19 to undergo FMT using their own frozen stool as placebo. Self-reported symptom improvement at 12 weeks served as the primary endpoint.
Among those who received FMT, 49% reported they experienced adequate relief of general IBS symptoms and abdominal bloating vs. 29% among those who received placebo (P = .004). Further, FMT patients reported significant improvements in discomfort (mean reduction, 19%; P = .001), reduced number of stools (mean reduction, 13%; P = .02), reduced urgency (mean reduction, 38%; P = .01), less abdominal pain (mean reduction, 26%; P = .001) and reduced flatulence (mean reduction, 10%; P = .04), while the placebo group did not. IBS-related quality of life also improved in the FMT group (16% improvement; P = .03).
Among 22 responders who were contacted at 1 year, six (27%) reported long-lasting effects, and five of them had been randomized to the FMT group.
Preliminary microbiota analysis of stool samples showed FMT induced significant changes to microbial composition, and these appeared to influence therapeutic success, Holvoet noted. – by Adam Leitenberger
Reference:
Holvoet T, et al. Abstract 617. Presented at: Digestive Disease Week; June 2-5, 2018; Washington, D.C.
Disclosures: Holvoet reports no relevant financial disclosures. Please see the DDW faculty disclosure index for a list of all other authors’ relevant financial disclosures.
Perspective
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Mark Pimentel, MD
If you asked me 3 years ago if I would have predicted a fecal transplant would work in IBS, I would have said absolutely not because our understanding is that in a certain fraction of IBS – probably 60% – it’s too much bacteria. With that in mind, adding more didn’t seem intuitive.
Now, it’s not quite as simple with FMT because you’re replacing the flora, but almost all the FMT trials of IBS so far have failed. This study showed success but there are two others that didn’t show any difference over placebo.
There may be some who will hang their hat on this positive trial, but I think on balance, we’re still not seeing an overly promising outlook for FMT in IBS.
The caution I have is, we shouldn’t be doing this outside of clinical trials because the FDA does not allow us to do it in anything other than Clostridium difficile. Unfortunately, there are people doing off-label FMT all the time for a variety of conditions. Anecdotally, the problem with that is we’ve seen more problems in IBS with FMT than we do see solutions. Patients will come in initially bloated and, after FMT, they’re far more bloated and more miserable.
The other thing that we haven’t quite teased out in IBS is even if FMT were to work, you don’t want to give FMT orally for IBS. In IBS, the small bowel is important, and an oral administration risks the capsule opening in the small bowel. If it were to work in IBS, it would be preferable to administer FMT colonoscopically.
There are more studies coming, but despite the study here, the verdict from this meeting is increasingly less enthusiasm for this technology or technique for IBS.
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