Medical Fun Facts Podcast

MFF0048: Gluten and FMT

If I’ve timed this correctly, tonight’s show is dropping on Thursday 16 March 2017.

A blogger and Facebook friend named Jules asked me recently, can gluten intolerance be treated with FMT?

There are three things to cover and I don’t expect I’ll really be able to answer the question given the controversy around gluten sensitivity.

Firstly, faecal microbiota transfer is a thing. In fact, I personally performed three stool transplants into three patients using my own stool in 1992. Each patient had an intractable infection caused by Clostridium difficile. After a few treatments with my super stool, each patient was cured. The process was simple enough, I’d defecate into a pan and then mix it with a little blood warm saline. I loaded up a catheter syringe and attached a rectal tube. I explained to the patient that I was inserting my super stool slurry into her rectum and she would have to hold for a minimum of 20 minutes. The longer the better. I usually injected about 100 mL knowing that anything >50 mL would result in reverse peristalsis and my stool would be moved up the patient’s descending colon to the splenic flexure. That would be sufficient.

Secondly, we should clarify what is meant by gluten intolerance. In <1% of humans, a genetic trait exists that confers gluten intolerance to the extent that damage is done to the small bowel wall and these people have a higher risk of bowel lymphoma. This is cœliac disease.

In Cœliac disease the patient’s immunological system mistakenly interprets gluten protein epitopes for foreign antigens and initiates a reaction. The immunological reaction also results in damage to the small bowel wall making Cœliac disease an autoimmune disorder. The damage results in chronic diarrhoea, malabsorption, and in children, failure to thrive.

The autoimmune response leads to shortened villi and eventually villous atrophy of the small bowel. This leads to malabsorption and anæmia.

The diagnosis is made by measuring the autoantibodies in serum, examining biopsies of the small bowel and genetic testing. The diagnosis isn’t always clear cut with non-reactive autoantibody serology not being uncommon and patchy villous atrophy making it difficult if normal areas of bowel are biopsied.

Treatment is the avoidance of gluten in wheat, barley and rye.

Thirdly, we have a growing number of people presenting with what is described as gluten intolerance but who do not have Cœliac disease. In some circles, this is now known as gluten sensitivity and the cause isn’t really known. Some investigators have labelled it a fad and not a real pathology, while there are many people who swear as soon as they adopt a gluten-free way of life their health improves enormously. There is also some data suggesting that gluten itself is protective against diabetes mellitus type II.

It’s not my area of expertise, so I don’t have a definitive opinion. Getting back to Jules’ question, though, would a stool transplant treat gluten sensitivity? I don’t know. Until we know the cause of gluten sensitivity it’s too early to say. FMT works by providing what is normally regarded as normal gut flora into what is assumed to be a deficient gut. That some people have tried it and feel their gluten sensitivity has improved is important to note but it’s not conclusive proof of cause and treatment.

FMT is not without its risks. Not all dangerous pathogens can be excluded and by its very nature, the exact make up of faeces remains a mystery. Many bacteria in our guts remain unidentified, uncharacterised and poorly understood.

So, Jules, I don’t know. Further research is necessary.

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