In 2013 the prestigious New England Journal of Medicine published a study of FMT in a nasty type of gut inflammation caused by the bug Clostridium difficile (C. difficile), a disease that kills up to one in 10 of its victims. The study was stopped early for a very unusual reason: FMT was so effective it was ruled unethical to withhold it from other participants in the study. If that all sounds a bit niche, be advised that FMT is gearing up to play to a wider audience. Evidence is mounting for its benefits in other gut problems, including ulcerative colitis, Crohn’s disease and irritable bowel syndrome. The gut also has complex connections with the brain and so altering the gut’s bug profile is, mind-bogglingly, the focus of research in depression, anxiety, autism, Parkinson’s disease, multiple sclerosis and obesity.

Wendy Bocci with her husband, Tom, who received a faecal transplant after recurring bouts with Clostridium difficile nearly killed him, at their home in Troy, Michigan, last year. Credit:New York Times And if that can’t entice you to step up for a poo transplant, the good news, depending on your world view of course, is that you can now swallow it, freeze-dried in a capsule - that’s 'crapsule' in the vernacular. So, is it just a matter of time before your next prescription reads, couched in civilised medical terms of course, “eat shit”? For Dean Morton, a 44-year-old finance manager from the NSW Central Coast, that time is now, and it’s no laughing matter. He had ulcerative colitis diagnosed in 2015 and the symptoms, including nausea, bloody diarrhoea and abdominal pain, have periodically flattened him. “I’d go to the toilet 12 times a day. I lost eight kilos in two weeks … there is an urgency when you need to go to the toilet. What that means is you’ve only got a few minutes from when you feel the need to go before you have an accident,” says Morton, who couldn’t work when the illness was at its worst.

Dean Morton of the NSW Central Coast is being treated for bowel issues with faecal transplant capsules. Credit:Max Mason-Hubers Morton was referred to Professor Thomas Borody, a gastroenterologist and FMT pioneer, who prescribed anti-inflammatory drugs and - the game changer, according to Morton - faecal capsules, made bespoke at Borody’s Sydney clinic. Morton, who takes four capsules each day, has been symptom-free since September 2016. “It feels fantastic. It allows me to live a normal life. It actually feels good to have hope, as well, that the condition is being cured. I believe it’s working,” he says. Morton’s belief may have good grounds. A trial published in The Lancet in early 2017, co-designed by Borody, found that FMT led to complete remission in just over one in four patients with ulcerative colitis. And a study in for JAMA, the Journal of the American Medical Association, in November found that for C. difficile, in which FMT is up to 90 per cent effective, crapsules worked just as well as FMT via colonoscopy.

How does it work? “When you put in stool, the bugs are capable of producing molecules that are able to kill the C. difficile. We also feel that similar mechanisms do this in patients with colitis … there are probably bacteria that cause colitis,” says Borody. You might think the yuck factor would put people off. The reality, according to Borody, is anything but. Professor Thomas Borody at the Centre for Digestive Diseases in Five Dock, NSW. Credit:Wolter Peeters “We don’t have to suggest it to anybody because people are breaking walls down just to try and come here for FMT. The trouble that we could have is the following; people wanting faecal transplants so they can be taller, to make their hair grow,” he says.

Indeed there is a whiff of snake oil about FMT, fuelled by its apparent promise across such a wide spectrum of disease. But the procedure is racking up some serious research attention. A trial underway at Massachusetts General Hospital, due for completion in June, is giving obese people faecal capsules sourced from lean people to see if they lose weight. It’s based on the idea that the gut microbiome – the roughly 1-2 kilos of bacteria that are permanent residents of your bowel – comes in lean and obese models. There is evidence that certain bugs allow more calories to be extracted from a given food mass and can trigger secretion of hunger-producing hormones such as ghrelin. In a dramatic case study from 2015, a woman got new-onset obesity after receiving FMT from an obese donor – her daughter. Poop researchers also have cancer in their sights. In January, a study in the journal Science reported that people who had good gut bacteria wiped out by antibiotics did worse on treatment for lung and kidney cancer. The finding may reflect yet another talent of gut bugs - to modify the immune system.

That special skill could also account for a particularly freakish result from FMT. In September, US-based gastroenterologist Colleen Kelly published two cases of people with alopecia, an autoimmune disease causing all-over hair loss, who got FMT to treat C. difficile. The C. difficile got better, but there was a bonus: Their hair grew back too. A lab technician at work at the Centre for Digestive Diseases. The centre manufactures faeces pills. Credit:Wolter Peeters Those people banging on the walls at Borody’s clinic might be onto something. Borody himself was involved in a study, published last year, that administered FMT to 18 children with autism spectrum disorder, an illness where bowel symptoms such as constipation and diarrhoea are common. Not only did FMT improve the gut issues, but classic autism traits, including poor social skills and communication, got better as well. It’s not clear exactly how, but a recent review points to a role for substances made in the gut under the influence of bacteria, including serotonin and gamma-Aminobutyric acid (GABA), that affect communication between brain cells. If that wasn’t enough, clinical trials are underway of FMT in multiple sclerosis, another illness where the immune system attacks the body instead of defending it. And a review published in January links the fatty acids produced by good gut bugs to lower blood pressure, raising the possibility of FMT as a future treatment for hypertension.

Gina Mendolia, product development associate at OpenBiome, the first stool bank in the US, in Massachusetts in 2015. Credit:New York Times Perhaps one of the most intriguing possibilities for the therapy, however, is in depression. Andre Schmidt, a neuroscientist at the University of Basel, is poised to begin the world’s first clinical trial of FMT in depression, which will test crapsules against placebos in 40 patients with moderate to severe forms of the illness. He’ll be sourcing the pills from OpenBiome which, if they work, could add to the ranks of a new class of drug; the “psychobiotic”. But the study, which was due to start in March, has been held up by red tape. Schmidt says that because FMT isn’t an approved treatment for depression, local regulators view the trial as high risk and are treading cautiously.

“Final approval requires … a good manufacturing practice certificate and to make sure that the production of FMT capsules is standardised,” he says. Poop in a pill: A capsule containing faecal microbes. Credit:New York Times Which raises the interesting question of just what comprises best practice when it comes to making poo. Schmidt will be sourcing faeces from six different donors, so thorough screening for pathogens is paramount. Ensuring the bugs are uniform across pills is also essential to know which ones are having an effect. How could poo possibly fix depression? A 2016 study found people with depression had markedly different gut bacteria from healthy controls that, when transplanted into mice, were linked to depression-like behaviour, such as immobility. An effect of healthy gut bugs on serotonin and GABA could offer a protective effect. Also, says Schmidt, good gut bugs may damp down inflammation, recently implicated as a factor in depression.

A 3D illustration of the Clostridium difficile bacillus. Over in the US, however, they’ve just ratcheted things up a notch. In January the largest FMT study in history enrolled its first subject. It is a collaboration between the American Gastroenterological Association and OpenBiome that aims to track 4000 patients, receiving FMT for a variety of disorders, over 10 years. In fact, for all conditions except C. difficile, you need to be part of a trial to get FMT in the US, which the Food and Drug Administration deems an “investigational new drug”. A spokeswoman for the Therapeutic Goods Administration said that in Australia, although faeces for transplant is considered “unapproved therapeutic goods”, there are exemptions in the relevant legislation that permit individual providers, such as Borody, to manufacture it for specific patients. Perhaps oddly, however, many of us may be getting doses of other people’s poo unwittingly. Marc Cohen, a professor of complementary medicine at RMIT University, points out that when we enter a communal pool we can’t help but ingest faeces, even if in small amounts. The standard health response is chlorination, a poison that not only fails to kill bugs such as Giardia but, says Cohen, is unpopular with owners of hot springs and spas keen to ensure a natural bathing experience.