Irritable bowel syndrome (IBS) is a common disorder of the intestines where patients suffer with symptoms such as cramping abdominal pain, bloating, flatulence and change in bowel habit - all suggestive of a chronic bowel flora infection (see The Unhealthy Human Bowel Flora). Those with constipation-predominant IBS (difficult or infrequent bowel movements) typically suffer bloating especially after meals, abdominal pains at times, tiredness, nausea, gas, reflux and in some situations headaches. The problem is known not to be caused by lack of fibre in the diet, inactivity or lack of water intake. However, many lay-people will advise the suffering patient to increase exercise levels and to drink more water in spite of the fact that this rarely helps. In those with mild constipation, increase of fibre intake can improve some symptoms, the fibre acting as a drug, but can worsen symptoms in others, particularly aggravating bloating. From accumulating evidence it is most likely that constipation is acquired as a bacterial infection of the bowel flora with the most likely culprit being a clostridium. The reasoning behind this takes into account the fact that constipation is a chronic, often hospital-acquired problem, eg. 10% of patients after a hysterectomy,14, 15 that improves significantly with the use of anti-clostridial agents such as vancomycin, 16 17 and can be reversed to normality after removing the infected constipated flora and replacement with an FMT. 18, 19 The PTRC is not aiming to treat mild or moderate forms of constipation but rather focuses on those patients in whom currently available standard therapy such as fibre, paraffin oil, motility stimulants, and other measures have failed to give the patient adequate relief. Several laxatives cause the bowel to become 'black' called pseudomelanosis and patients can develop insensitivity or become resistant to these medications over time. Hence, FMT offers a therapy of last resort to patients where other therapies for constipation have been ineffective or where symptoms continue in spite of treatment.
On the basis that constipation is an infection of the bowel flora with a 'yet-to-be-described' clostridial bacterium, which also appears to have spores, a course of vancomycin can dramatically improve the constipation 16, 17 but is unable to cure the infection except on rare occasions.17 FMT can be carried out in several ways. Most commonly a short course of antibiotics is given to reduce the bacterial load in the bowel and the mucosal surfaces of the bowel, then the flora is removed by a lavage solution consumed by the patient similar to that carried out prior to colonoscopy. The bowel flora is then replaced by a series of enemas so implanting new bacteria to eradicate the presumed clostridial spores by the incoming flora - which is known to eradicate C. difficile spores. 6, 7 This treatment has major advantages over laxative therapies because it can be curative and also alleviate other motor, fermentative and peristalsis abnormalities such as slow gastric emptying, reflux, bloating, nausea, dysphagia and in some patients, chronic tiredness.