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Fecal Microbiota Transplantation in Inflammatory Bowel Disease: A Primer for Internists

Inflammatory bowel disease is characterized by an aberrant immune activation in genetically susceptible individuals, leading to gut inflammation. Despite recent therapeutic advances in inflammatory bowel disease, a substantial proportion of patients do not respond to the currently available drugs. Moreover, there are concerns regarding potential long-term consequences of immunosuppressive therapy. Thus, researchers have sought methods of altering gut microbiota for therapeutic benefit. For many years, prebiotics and probiotics have been tried in inflammatory bowel disease, with mixed results.1, 2 More recently, the success of fecal microbiota transplantation in treatment of Clostridium difficile infection3 has sparked interest in the utility of fecal microbiota transplantation in treatment of inflammatory bowel disease.

Search Strategy

A literature search using the PubMed, Medline, and Embase databases from the year 1950 to October 2017 was conducted to identify studies that investigated the use of fecal microbiota transplantation in treatment of inflammatory bowel disease. Keywords used were “fecal microbiota transplantation” (fecal or faecal or stool, microbiota or microbiome, transplantation or transplant or instillation or administration or infusion or transfer) and “inflammatory bowel disease,” “ulcerative colitis,” or “Crohn’s disease.” The reference lists of the clinical reviews, systematic reviews, and meta-analyses identified with the above search criteria were also reviewed to identify any additional relevant publications that may have been missed.

Current Medical Therapy for Inflammatory Bowel Disease

Disease severity and activity are the 2 most important factors determining the treatment choice in inflammatory bowel disease. Disease activity is a cross-sectional estimation of inflammatory burden determined by a combination of clinical symptoms, laboratory parameters, and endoscopic features and can change over time. The most commonly used tools for clinical disease activity assessment for ulcerative colitis are the modified Mayo Clinic score and the simple clinical colitis activity index, which include parameters like stool frequency, nocturnal stools, fecal urgency, rectal bleeding, and general well-being. Similarly, the Crohn’s disease activity index is a well-validated clinical activity index for Crohn’s disease that uses several factors, such as number of liquid stools, abdominal pain, general well-being, extra-intestinal complications, use of antidiarrheal drugs, abdominal mass, hematocrit, and body weight, toward calculation of a total score. However, it is cumbersome to use in clinical practice, and its use is largely restricted to research. Laboratory parameters helpful in determining disease activity in both ulcerative colitis and Crohn’s disease include C-reactive protein, erythrocyte sedimentation rate, fecal calprotectin, and fecal lactoferrin. Commonly used endoscopic activity scores include the Mayo Clinic endoscopic score for ulcerative colitis and simple endoscopic score for Crohn’s disease. Disease severity is less clearly defined and refers to an overall assessment of disease behavior encompassing historical and longitudinal factors like history of surgical resection, fistula, stricture, and prior medication use, irrespective of the disease activity at a point in time.4

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-Gaurav Syal, MD, Amir Kashani, MD, David Q. Shih, MD, PhD

This article originally appeared in the September issue of The American Journal of Medicine.

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