Gulp: Adventures on the Alimentary Canal (36 page)

Khoruts works the control buttons with his left hand, torquing the tube with his right. I comment that it’s like playing an accordion or a piano, both arms working independently at unrelated tasks. Khoruts, who plays piano in addition to colonoscope, prefers the analogy of the amputee’s prosthesis. “Over time it becomes part of your body. Even though I don’t have nerve endings there, I kind of know what’s happening.”

We’re in now, heading north. The man’s heartbeat is visible as a quiver in the colon wall. Khoruts maneuvers a crook. Shifting a patient’s position can help unkink a sharp turn, so the nurse leans in hard, like a driver pushing a stall to the shoulder of the road.

Using a plunger on the control head, Khoruts releases a portion of the transplant material. Since the colon has been wiped clean beforehand with antibiotics, the unicellular arrivals won’t have to battle a lot of natives. However many survived the antibiotic, the immigrants are sure to prevail. Within two weeks, Khoruts’s research shows, the microbial profiles of donor and recipient colons are synced.

One more release, at the far end of the colon, and Khoruts retracts the scope.

A couple days later, Khoruts forwards an e-mail from the patient (with surname deleted). The pain and diarrhea that had kept him from going to work for a year were gone. “I had,” he wrote, “a small solid bowel movement on Saturday evening.” It may not be your idea of an exciting Saturday evening, but for Mr. F., it was tough to top.

• • •

T
HE FIRST FECAL
transplant was performed in 1958, by a surgeon named Ben Eiseman. In the early days of antibiotics, patients frequently developed diarrhea from the massive kill-off of normal bacteria. Eiseman thought it might be helpful to restock the gut with someone else’s normals. “Those were the days when if we had an idea,” says Eiseman, ninety-three and living in Denver at the time I wrote him, “we simply tried it.”

Rarely does medical science come up with a treatment so effective, inexpensive, and free of side effects. As I write this, Khoruts has done forty transplants to treat intractable
C. diff
infection, with a success rate of 93 percent. In a University of Alberta study published in 2012, 103 out of 124 fecal transplants resulted in immediate improvement. It’s been fifty-five years since Eiseman first pushed the plunger, yet no U.S. insurance company formally recognizes the procedure.

Why? Has the “ick factor” hampered the procedure’s acceptance? Partly, says Khoruts. “There is a natural revulsion. It just doesn’t seem right.” He thinks it has more to do with the process by which a new medical procedure goes from experimental to mainstream. A year after I visited, the major gastroenterology and infectious disease societies invited “a little band of fecal transplant practitioners” to put together a “best practice” paper outlining optimal procedures: a common first step toward establishing codes for billing for the procedure and making the case for insurance companies to cover it. As of mid-2012, there was no billing code or agreed-upon fee. Khoruts estimates the process will take one to two years more. In the meantime, he simply bills for a colonoscopy.

The extent to which health care bureaucracy stands in the way of better patient care is occasionally astounding. It took a year and a half for Khoruts’s study on bacteriotherapy for recurrent
C. diff
infection to be approved by the University of Minnesota’s Institutional Review Board (IRB)—which oversees the safety of study subjects—even though the board had no substantive criticisms or concerns. The morning I visited to see the transplant, Khoruts showed me an object I wasn’t familiar with, a winged plastic bowl called a toilet hat
^*
that fits over the rim of the bowl to catch the donor’s produce. “That caused about two months of delay on the IRB protocol,” he said. “They sent it back saying, ‘Who’s going to pay for the toilet hats?’ They’re fifty cents apiece.”

Khoruts has also been working on a proposal for a study to evaluate fecal transplants for treating ulcerative colitis.
^†
Inflammatory bowel diseases—irritable bowel syndrome, ulcerative colitis, Crohn’s disease—are thought to be caused by an inappropriate immune response to normal bacteria; the colon gets caught in the cross fire. This time around, the IRB refused to approve the trial until the FDA had approved it. And that’s just for the trial. Final FDA approval, the kind that makes the procedure available to anyone, is a costly process that can take upward of a decade.

And in the case of fecal transplants, there’s no drug or medical device involved, and thus no pharmaceutical company or device maker with diverticuli deep enough to fund the multiple rounds of controlled clinical trials. If anything, drug companies might be inclined to fight the procedure’s approval. Pharmaceutical companies make money by treating diseases, not by curing them. “There’s billions of dollars at stake,” says Khoruts. “I told Katerina, if this works, don’t be surprised to find me at the bottom of the river.”

We are sitting in Khoruts’s office, in between colonoscopies. Above our heads, on a shelf, is a lurid plastic life-size model of a human rectum afflicted by every imaginable malady: hemorrhoid, fistula, ulcerative colitis, fecaliths. Metaphor for the U.S. health care system?

Khoruts smiles. “Bookend.” A drug company was giving them away at Digestive Disease Week, an annual convention of gastroenterologists and drug reps, with the occasional person dressed as a stomach, handing out samples.

While the bureaucracy inches forward, fecal transplants for
C. diff
are quietly carried out in hospitals in thirty states. But that leaves twenty where patients have no access. Some have turned to what a researcher in one
Clinical Gastroenterology and Hepatology
paper called “self-administered home fecal transplantation.” Though seven of seven
C. diff
sufferers were cured by self-or “family-administered” transplants using a drugstore enema kit, it doesn’t always go well. One woman who recently e-mailed Khoruts for advice didn’t follow directions. She put tap water in the blender, and the chlorine killed the bacteria. Another in-home transplant replaced one source of diarrhea with another: fecal parasites contracted from the donor. Rather than protecting patients, IRBs—with their delays and prodigious paperwork—can put them in harm’s way.

Fecal bacteriotherapy will quickly become more streamlined. More sophisticated filtration will enable the separation of cellular material from ick. The bacteria can then be dosed with cryoprotectant—to prevent ice crystals from puncturing the cells—frozen, and shipped where it’s needed, when it’s needed. Khoruts’s operation is already headed this way.

The Holy Grail would be a simple pill, along the lines of the lactobacillus suppositories used to cure recurrent yeast infection. Generally and unfortunately, aerobic strains that are easy to grow and keep alive in the oxygen environment of a lab are unlikely to be the beneficial ones. Though researchers don’t know exactly which bacteria are the desirables, they do know they’re likely to be anaerobic species that thrive only within the colon. You want the creatures that are dependent on a healthy you for their own survival, the ones whose evolutionary mission is aligned with your own—your microscopic partners in health.

I asked Khoruts what exactly is in the “probiotic” products seen in stores now. “Marketing,” he replied. Microbiologist Gregor Reid, director of the Canadian Research & Development Centre for Probiotics, seconds the sentiment. With one exception, the bacteria (if they even exist) in probiotics are aerobic; culturing, processing, and shipping bacteria in an oxygen-free environment is complicated and costly. Ninety-five percent of these products, Reid told me, “have never been tested in a human and should not be called probiotic.”

I
PREDICT THAT ONE
way or another, within a decade, everyone will know someone who’s benefited from a dose of someone else’s body products. I recently received an e-mail from a doctor in Texas, telling me the story of Lloyd Storr, a Lubbock physician who treated chronic ear infections via homemade “earwax transfusions”: drops of donor earwax boiled up in glycerin. Earwax maintains an acid environment that discourages bacterial overgrowth and possibly contains some antibacterial chemicals. Whatever it does, some people’s works better than others’. Khoruts has been encouraging a friend of his, a periodontist, to try bacterial transplantation
^*
as a treatment for gum disease.

If things go as they should, the bacteria hysteria so lucratively nurtured by the likes of Purell and Lysol will begin to subside. Thanks to the courageous blender-wielding pioneers of bacterial transplantation, fussiness and unfounded fear will be buffered by rational thinking and perhaps even a modicum of gratitude.

A tip of the toilet hat to you, Alexander Khoruts.

T
HE GREAT IRONY
is that in the beginning, the gut was all there was. “We’re basically a highly evolved earthworm surrounding the intestinal tract,” Khoruts commented as we drove away from his clinic the last day I was there. Eventually, the food processor had to have a brain attached to help it look for food, and limbs to reach that food. That increased its size, so it needed a circulatory system to distribute the fuel that powered the limbs. And so on. Even now, the digestive tract has its own immune system and its own primitive brain, the so-called enteric nervous system. I recalled what Ton van Vliet had said at one point in our conversation: “People are surprised to learn: They are a big pipe with a little bit around it.”

You are what you eat, but more than that, you are
how
you eat. Be thankful you’re not a sea anemone, disgorging lunch through the same hole that dinner goes in. Be glad you’re not a grazer or a cud chewer, spending your life stoking the furnace. Be thankful for digestive juices and enzymes, for villi, for fire and cooking, all the miracles that have made us what we are. Khoruts gave the example of the gorilla, a fellow ape held back by the energy demands of a less streamlined gut. Like the cow, the gorilla lives by fermenting vast quantities of crude vegetation. “He’s processing leaves all day. Just sitting and chewing, and cooking inside. There’s no room for great thoughts.”

Those who know the human gut intimately see beauty, not only in its sophistication but in its inner landscapes and architecture. In a 1998 issue of the
New England Journal of Medicine
, two Spanish physicians published a pair of photographs: “the haustrations of the transverse colon” side by side with the arches of an upper-floor arcade in Gaudi’s La Pedrera. Inspired, wanting to see my own internal Gaudi, I had my first colonoscopy without drugs.
^*

There is an unnameable feeling I’ve had maybe ten times in my life. It is a mix of wonder, privilege, humility. An awe that borders on fear. I’ve felt it in a field of snow on the outskirts of Fairbanks, Alaska, with the northern lights whipping overhead so seemingly close I dropped to my knees. I am walloped by it on dark nights in the mountains, looking up at the sparkling smear of our galaxy. Laying eyes on my own ileocecal valve, peering into my appendix from within, bearing witness to the magnificent complexity of the human body, I felt, let’s be honest, mild to moderate cramping. But you understand what I’m getting at here. Most of us pass our lives never once laying eyes on our organs, the most precious and amazing things we own. Until something goes wrong, we barely give them thought. This seems strange to me. How is it that we find Christina Aguilera more interesting than the inside of our own bodies? It is, of course, possible that I seem strange. You may be thinking,
Wow, that Mary Roach has her head up her ass.
To which I say: Only briefly, and with the utmost respect.

*
Not one was eaten. Research by University of Pennsylvania disgust expert Paul Rozin would have predicted a 57 percent consumption rate. In his study, subjects were asked whether they’d be willing to eat “fudge curled to look like dog feces.” It is a powerful taboo. Twelve percent refused to even touch it, even though they knew it was fudge.

*
It’s called the FATLOSE trial. FATLOSE stands for “Fecal Administration To LOSE weight,” an example of PLEASE—Pretty Lame Excuse for an Acronym, Scientists and Experimenters.

*
“Hi Mary—After reaching out to our Oster product team and reviewing the information you sent me, we have come to the conclusion that we prefer not to comment on this subject matter.”

*
Kung pao chicken, if I had to guess.

*
Or, less often, a nun’s hat, because of the resemblance to the Flying Nun–style wimple. Catholic nurses and hospital patients have from time to time voiced their indignation, and the term has been mostly retired.

†
Typing
colitis
reliably brings “Lucy in the Sky with Diamonds” into my head. In my favorite case of mistaken lyrics, someone heard “The girl with kaleidoscope eyes” as “The girl with colitis goes by.”

*
Kissing is a less aggressive form of bacterial transplant. Studies of three different gingivitis-causing bacteria have documented migration from spouse to spouse. Periodontically speaking, an affair might be viewed as a form of bacteriotherapy.

*
Not typically a big deal. Most Europeans get scoped with sedation-on-demand. You’re set up with an IV ready to go, and need only say the word. Eighty percent never ask for the drugs.

Acknowledgments