An Elegantly Icky Solution

I’d love to shield the identity of the patient in this story. But I can’t, and you’ll understand why in a minute. It’s not that I’m worried about a HIPAA violation or a law suit. After all, the patient was my mother-in-law. She and my father-in-law – Pop Pop – have moved in with us . . . so they aren’t going to sue anybody. And while I hesitate to embarrass my soft-spoken “Mom Mom” with the details of this tale, I have to tell this story straight. Here goes.

I’d love to shield the identity of the patient in this story. But I can’t, and you’ll understand why in a minute. It’s not that I’m worried about a HIPAA violation or a law suit. After all, the patient was my mother-in-law. She and my father-in-law – Pop Pop – have moved in with us . . . so they aren’t going to sue anybody. And while I hesitate to embarrass my soft-spoken “Mom Mom” with the details of this tale, I have to tell this story straight. Here goes.

Mom Mom is a frail 83-year-old who weighs less than 100 pounds soaking wet. So any time she gets sick, she gets really sick, really quick. And like any other 83-year-old she’s been sick a time or two. Her 40-degree kyphoscoliosis, her surgically corrected L4-5 spondylolisthesis, and total hip replacement give her plenty of reason to complain about pain in her back, hips, and legs. So it was no surprise when she added one more thing to the list…toe pain.

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Her podiatrist felt the pain was related to the presence of a rather large wart and suggested surgical excision. The surgery went well despite his reporting that he had to “drill down almost to the bone.” Hearing this I began to worry about a post-op infection and warned her to watch for redness, warmth, swelling, and streaks up her leg. Whether it was real or suggested, three days post op she began complaining of all the above. Being as concerned as I was, her podiatrist erred on the side of caution and prescribed Augmentin. When I finally got free to visit her and examine the toe, I realized that the podiatrist had possibly been pressured into overtreating her. Her toe wasn’t the least bit infected and hadn’t been since surgery.

Oh well, a little unnecessary Augmentin never hurt anybody, right? Unfortunately, this is not true. Mom Mom developed a rip roaring case of diarrhea, which soon tested positive for clostridium difficile toxin. She was admitted to the hospital and treated with vancomycin and flagyl. She felt horrible and looked worse. She finally recovered enough to go home, but when she did we realized that she had dropped about seven pounds that she couldn’t afford to lose. Nothing that a little Ensure and a lot of good home cookin’ won’t cure, right? Wrong again. Though she tried her best to eat everything placed in front of her, her diarrhea never really abated. Being a stoic, she never complained. In fact, to her detriment, she hid the fact that she was still sick. I’m assuming that she was just hoping the ‘doctors’ – including me – would just leave her alone and let her get well without more intervention.

Unfortunately, that didn’t work. Rather quickly she reached a tipping point of watery diarrhea, dehydration, and impaired renal function. When, late one night, she reached the point of not being able to walk to the bathroom, Pop Pop called an ambulance. In a state of reckless delirium, Mom Mom refused their help, telling the “ambulance boys” to go home, that she “would be fine.” By 9 am when I received the call that she was on her way to the hospital, her blood pressure was starting to drop to dangerous levels. I raced to the hospital that morning, and upon entering the exam room, my first impression was that she was very near death.

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Thanks to the fine work of some emergency physicians, that was not the end of the story. Instead, over the next several days she returned to her steady state of C. diff infection. Her po Vancomycin and IV Flagyl seemed to be helping. But she was weaker now. She had moved down the ladder a step or two. The hope was that she would gradually improve, but the literature paints a bleaker picture – studies indicate that a 30% to 60% relapse rate could be expected. Moreover, if the antibiotics didn’t help, or if the recently developed super antibiotic didn’t do the trick, she was looking at a possible total colectomy. We had a family meeting. We didn’t think she would tolerate such a radical procedure. But what could we do?

We first turned to some home remedies that various people recommended. Probiotics were suggested by many who has seen marked improvement. We tried it and saw some gains, but nothing seemed to address the basic underlying problem. The antibiotics had wiped out Mom Mom’s gut flora so badly that the C. diff was virtually unopposed. We knew that as soon as we stopped the high potency antibiotics, it was only a matter of time until she had another flare up.

And this, dear reader, is when things got a little interesting. I came across a novel therapy written up in JAMA called “fecal transplantation.” Simply put, it involved taking stool from a healthy “donor,” with all its 400+ normal bacterial flora, and “transplanting” it into a recipient via enema.

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It sounded elegantly icky. But it seemed like it just might be the magic bullet. Surely, I thought, someone is performing this procedure around here. When I discussed the topic with an infectious disease specialist from the National Institutes of Health, she agreed with the published results of the research – up to 83% success rate, sometimes within hours. But no one, at least no one we could get in to see any time soon, had a protocol for performing the “transplant”.

Why not, I thought. It was so simple. It wasn’t a drug, so a study protocol didn’t fall under the FDA. It wasn’t really going to make much money. How can you charge a butt load (I’m sorry, I couldn’t pass it up) for a stool enema?

Finally, in frustration, I sat down with Mom Mom and discussed the option of just doing this procedure at home. Just the thought of trying to delicately explain the procedure to my mother-in-law and gain her permission had me in a cold sweat. But bless her heart, she was so trusting. She was willing to do anything to get well.

So I went and bought a new blender, my wife having refused me the good Kitchen Aid sitting in the kitchen. I got a good “fecal donation” from a healthy source who shall remain nameless. I made sure the donor was free of any exposure to parasites or other gut pathogens. Then I mixed the concoction with sterile saline, following the recipe reported by a gastroenterologist at Johns Hopkins who is promoting the procedure. The hardest part was cautiously pouring the mixture into the brand new enema bag. I delivered the “transplant” apparatus to my daughter, a nursing student, for administration, doing my best to act like it was a routine procedure. After receiving the transplant we had Mom Mom lie on her left side for 30 minutes before going to the toilet. All in all, it was rather simple, quick, painless, and easy to administer.

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At this point Mom Mom had suffered six weeks of nearly constant diarrhea and had taken over $1000 worth of Vancomycin. I didn’t know what to expect. But 48 hours later, Mom Mom got up one morning and cheerily announced, “I’m fine now,” and began eating everything in sight.

What? That’s it? You mean that we put her through six weeks of hell and all we had to do was give her a stool enema? That’s right, folks. That was it.

It’s been three month now since her home treatment. She’s had no more Vancomycin, probiotics, or diarrhea. She eats like a champ and is gaining weight steadily. And I can’t stop reading about all the benefits of a healthy gut flora. I don
’t want to sound like some wacky convert, but this really cured a very sick elderly woman, and quickly.

I can’t help but think about all those people on the C. diff wards at hospitals around the country waiting to have their colons removed.

I’m thinking about starting a donor drive. But I’m having a hard time coming up with a good slogan to go on the buttons.