I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information.
Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources.
I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract.
During my fellowship, I had the opportunity to work with some of the most amazing pediatric gastroenterologists and mentors. Some of these individuals included Mitchell Cohen, William Balistreri, James Heubi, Jorge Bezerra, Colin Rudolph, John Bucuvalas, and Michael Farrell. I am grateful for their teaching and their friendship. During my training with their help, I received a nationwide award for the best research by a GI fellow.
I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. In addition, I have been recognized by Atlanta Magazine as a "Top Doctor" in my field multiple times.
Currently, I am the vice chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN), American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation.
As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids), I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, hepatitis C, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources.
I am fortunate to work at GI Care For Kids. Our group has 17 terrific physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. Our group of physicians have worked closely together for many years. None of the physicians in our group have ever left to join other groups. I have also worked with the same nurse (Bernadette) since I moved to Atlanta in 1997.
For many families, more practical matters about our office include the following:
– 14 office/satellite locations
– physicians who speak Spanish
– cutting edge research
– on-site nutritionists
– on-site psychology support for abdominal pain and feeding disorders
– participation in ImproveCareNow to better the outcomes for children with inflammatory bowel disease
– office endoscopy suite (lower costs and easier scheduling)
– office infusion center (lower costs and easier for families)
– easy access to nursing advice (each physician has at least one nurse)
I am married and have two sons (both adults). I like to read, walk/hike, bike, swim, and play tennis with my free time.
I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have helped enroll patients in industry-sponsored research studies.
Methods: Retrospective analysis of High Resolution Impedance Manometry (HRiM) with belch provocation was performed between May 2021 and April 2024 in 55 patients with R-CPD, 30 control patients, and 15 healthy volunteers. Age of patients with R-CPD was 22-35 years.
Key findings:
During belching, we saw higher UES pressures in R-CPD patients vs controls, leading to incomplete air clearance and air oscillating in the esophagus (P < .0001)
After BT injection, median UES pressures during belching decreased (56 vs 3 mmHg), and air clearance improved (P < .0001)
A maximum UES pressure during belching >31 mmHg adequately discriminated patients from controls
Interestingly, the authors did not include one of the major findings in their abstract: “Symptom improvement of at least 50% was present in 57% of patients, which is lower than reported up to now”
R-CPD patients had inability to belch in 100%, gurgling chest noises in 100%, bloating in 92%, chest pain in 67%, nausea in 59%, and heartburn (at least weekly) in 65%
My take: Recognition of this treatable disorder is important. However, the lower improvement rate in this study is useful for counseling patients. My suspicion is that this finding likely reflects more widespread results as initial studies could have more selection or reporting bias.
B Kang et al. Clinical Gastroenterology and Hepatology; 2026: 24: 201 – 209. Proactive Drug Monitoring Versus Clinically Based Dosing for Endoscopic Healing in Pediatric Crohn’s Disease Receiving Infliximab
Methods: This was a non-blinded, randomized controlled trial of 112 biologic-naïve children with CD who had responded to IFX induction treatment at 4 centers in South Korea between July 2017 and November 2020. Patients were randomly assigned to receive dosing based on proactive TDM (proactive arm) or clinically based dosing (clinical arm). The primary endpoint was endoscopic healing (EH) at week 54.
During the maintenance phase, patients received IFX 5 mg/kg every 8 weeks. In the proactive arm, treatment was intensified (shortening interval by 2- to 4-weeks) if trough level was less than 6 mcg/mL.
“Our findings provide evidence that the proactive strategy resulted in increased EH rates and had a positive impact on SCFCR, biochemical remission, and FC, which serve as surrogate markers of EH.”
“The PAILOT trial, the only prospective study on proactive TDM in pediatric patients with CD, demonstrated that proactive TDM with adalimumab resulted in higher SCFCR rates than reactive TDM (82% vs 46%; P < .001), consistent with our findings.8“
“In our study, IMM [immunomodulator] modulation was performed in conjunction with proactive TDM, which may explain why no difference was observed in ADA development (proactive arm, 31.4% vs clinical arm, 28.6%. Proactive TDM has been confirmed to reduce the development of ADAs, and the concept of “optimized monotherapy” based on the view that proactive TDM effectively guides IMM withdrawal in combination therapy has been well-described.30 …in our institution, IMMs are discontinued as soon as possible after 1 year of combination therapy if adequate TDM is maintained.31“
My take: This study shows that proactive TDM is superior to clinical-based dosing. The findings may have been less pronounced if higher baseline doses of IFX were used. It is well-recognized that “standard” IFX (5 mg/kg/dose every 8 weeks) is usually insufficient in pediatric patients.
O Ackermann et al. Gastroenterol 2026; 170: 188-198. The Natural History of Gastroesophageal Varices in Children With Portal Hypertension
Methods: Retrospective review of 1586 children with portal hypertension. 590 had two or more upper endoscopies (403 with biliary atresia).
“For the purpose of this study, and based on our previous experience in children,8,11 the endoscopic pattern associated with a high risk of bleeding (ie., HRV) included grade 3 esophageal varices as well as grade 2 esophageal varices with red color signs or gastric varices (cardia), or both.”
The authors developed a HRV [high risk of varices] score as a composite index calculated as follows: 1 point for grade 1 esophageal varices, 2 points for grade 2 varices, 3 points for grade 3 varices, and 1 point each for the presence of red color signs or GOV1 (HRV score range, 0–5). High-risk varices had an HRV score of 3 to 5.
Key findings:
Worsening of the endoscopic pattern occurred in 58% of children over a mean 4-year interval
5- and 10-year probabilities of HRV emergence in initially HRV-negative children were 36% and 54%, respectively
Infants with biliary atresia are at particularly high risk with correlation to the degree of cholestasis (see below)
Platelet count less than 150,000 as an indicator of HRV was mainly useful in older children. “A platelet count of ≥150,000/mm3 was recorded in 205 of the 629 children (32%) with HRV. Moreover, there was a decrease with age in the proportion of children with HRV and a platelet count of ≥150,000/mm3, falling from 62% in children aged <12 months to 2% in patients aged >10 year.” 16% of children 6-8 yrs, 12% of children 8-10 years of age with HRV had platelet count ≥150,000/mm3
“Gastrointestinal bleeding was recorded in 36 of 947 children (3.8%) who did not have HRV at their last endoscopy and in 270 of the 359 children (75%) with HRV at their last endoscopy who did not undergo endoscopic or surgical primary prophylaxis of bleeding.”
Bilirubin of 100 micoMol is equivalent to 5.8 mg/dL and 17.1 is eqivalent to 1 mg/dL
Discussion Points:
Variceal progression was much faster in infants and is is likely due to the severity of cholestasis and its impact on portal hypertension.
“It is notable that children with Alagille syndrome and those with genetic cholestasis with normal GGT have a lower rate of variceal progression and a lower mean HRV score than children with biliary atresia, despite comparably high levels of bilirubin. This suggests that different mechanisms of cholestasis … may have distinct consequences on intrahepatic portal vein branches resulting in varying degrees of portal hypertension.”
“In children with biliary atresia aged <12 months, grade 2 esophageal varices without red color signs or GOV1 (HRV score of 2) should be considered an indication for endoscopic primary prophylaxis.”
“Because the efficacy and safety of β-blockers have not been established in children, we suggest that this pattern—grade 1 varices with red color signs or GOV1—should prompt early repeat endoscopy to detect HRV in a timely manner…this repeat endoscopy could be recommended 6 months after the previous one.”
Limitations: High proportion of children with biliary atresia (limits conclusions with other disorders), and retrospective study since 1990
“Pending the results of future studies, the detection of palpable splenomegaly remains a simple and practical criterion for initiating screening endoscopy in children with portal hypertension”
My take: This is a very useful study providing important data to help improve decision-making in children with portal hypertension.
Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure. This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition.
This single-center observational study (n=254) examined the correlation between fecal calprotectin (FC) levels with both disease extent and mucosal healing in ulcerative colitis. Mucosal healing was rated by the Mayo Endoscopic Score (MES).
Key findings:
Disease extent: FC levels were significantly lower in proctitis (440 mg/kg) as compared with left-sided colitis (840 mg/kg) or pancolitis (1,690 mg/kg)
Mucosal healing: In MES ≤1, FC levels were significantly lower in proctitis (24) compared to left-sided colitis (40) or pancolitis (85)
My take: Fecal calprotectin levels are clearly affected by the extent of disease involvement. However, the increase in calprotectin values associated with disease activity was significantly larger than the differences attributed to disease extent.
Methods: This post hoc analysis assessed data from a 12-week, randomized, double-blind, placebo-controlled phase 3 study (NCT02605837) of budesonide oral suspension (BOS) 2.0 mg twice daily in patients (n=318) aged 11–55 years with EoE and dysphagia. Coprimary efficacy outcomes were histologic (≤ 6 eosinophils per high-power field [eos/hpf]) and dysphagia symptom (≥ 30% reduction in Dysphagia Symptom Questionnaire scores from baseline) responses at week 12.
Key findings:
Histologic responses (≤ 6 and < 15 eos/hpf) were similar regardless of dilation history
Fewer BOS-treated patients with dilation history than no dilation history achieved a dysphagia symptom response (44.0% vs 59.0%)
Discussion Points:
“Esophageal dilation may provide immediate relief from dysphagia (15); symptom improvement has been observed in 95% of dilated patients with EoE (29)…[however] dilation does not affect the underlying inflammation (18).”
“A histologic response (<15 eos/hpf) to swallowed corticosteroids has also been associated with a reduced number of repeat esophageal dilations required to maintain a similar esophageal caliber compared with nonresponse (≥15 eos/hpf)…this supports swallowed corticosteroid use in patients who have undergone esophageal dilation, even in the absence of acute symptom improvement.”
“Study limitations include potential enrollment of patients with severe disease due to stringent inclusion criteria.”
My take: While dilatation alone often improves symptoms, treatment with budesonide may help reduce need for repeat dilatations.
CFD Li Wai Suen et al.Gastroenterology, Volume 170, Issue 1, 118 – 131. Early Infliximab Levels and Clearance Predict Outcomes After Infliximab Rescue in Acute Severe Ulcerative Colitis: Results From PREDICT-UC
Methods: Data, including serum and stool testing, was extracted from from 135 patients (ages 24-42) enrolled in the PREDICT-UC prospective, randomized controlled trial
Key findings:
Lower day 3 serum infliximab levels predicted infliximab failure on day 14 and colectomy by 3 months; a threshold of ≤57.9 μg/mL had 83% sensitivity, 67% specificity, 24% positive predictive value, and 97% negative predictive value for colectomy
In patients with high clearance who did not respond to the first infliximab dose, day 14 response rate was higher with a second 10 mg/kg vs 5 mg/kg dose (38% vs 11%; risk ratio, 3.43)
Day 3 fecal infliximab levels correlated with endoscopic severity and was associated with day 7 nonresponse (P = .016)
Discussion points:
“Early infliximab levels and clearance predict outcomes in ASUC. Additionally, we are the first to demonstrate that a high early infliximab clearance can be overcome by additional dosing. These results demonstrate the potential of early infliximab TDM [therapeutic drug monitoring] to guide decision-making in ASUC and for the first time provide an evidence base for intensified infliximab dosing in clinical practice.”
My take: While the authors suggest TDM as a potential strategy to overcome low levels, an alternative approach would be using higher dosing and more frequent dosing, especially as infliximab levels may not be quickly available. Higher dosing is particularly important in the pediatric age group where studies have shown that “standard” dosing of 5 mg/kg result in insufficient levels of infliximab in ~80%.
Background: “Mechanisms by which fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAPs) drive pathophysiology of irritable bowel syndrome (IBS) are not well understood.”
Methods: 42 patients with “Rome IV diarrhea-predominant IBS (IBS-D) underwent barrier function evaluation pre- and post-LFD along with assessment of mast cell number and activation profile. Finally, fecal supernatants (FS) were administered intracolonically to wild-type mice with and without pharmacologic inhibition, toll-like receptor 4 (tlr4)–/– mice, and mast cell-deficient mice with/without mast cell reconstitution.”
Key findings:
This is a highly technical study and would recommend reviewing the findings directly (open access article).
To summarize:
“Patients with IBS-D had significant improvement in colonic barrier structure and function, mast cell number, and levels of mast cell mediators post-LFD (low FODMAP diet). The magnitude of physiological changes did not correlate with the magnitude of clinical response.”
“This study showed the complex interplay among food, microbiome, local immune activation, and epithelial physiology in IBS by demonstrating that FODMAPs increase fecal lipopolysaccharide levels, which activates colonic mast cells to causes barrier dysfunction in diarrhea-predominant IBS.”
My take: By understanding the GI effects of a low FODMAP diet in patients with IBS-D more precisely, it may improve dietary approaches as well as other treatments like mast cell stabilizers.
Background: “Obesity has historically been defined using body mass index (BMI). However, BMI does not account for adipose tissue, limiting its accuracy. The Lancet Diabetes & Endocrinology Commission created a revised obesity definition including anthropometric measures (waist circumference [WC], waist-to-hip ratio [WHR], and waist-to-height ratio [WHtR]),1 encompassing and subcategorizing preclinical obesity (excess adiposity without organ dysfunction or physical impairment) and clinical obesity (a disease).”
Methods: The authors analyzed 14,414 participants representing 237,700,000 US adults. using the 2017-2023 National Health and Nutrition Examination Survey (NHANES)
Key findings:
Survey-weighted obesity prevalence was 75.2%
Obesity was noted in 100% among adults with BMI of 30 or greater, 80.4% with BMI 25 to less than 30, and 38.5% with BMI less than 25
Discussion Points:
“These findings demonstrate the impact of anthropometric thresholds, particularly since 80.0% of adults had waist-to-height ratio [WHtR]) above 0.5. Though this value was cited by the Lancet Commission and identifies cardiometabolic risk,1,4,5 the commission emphasized that additional research was required for this cutoff.1“
My take: This is a provocative study indicating that even more U.S. adults could be considered obese when incorporating anthropometric criteria. More data is needed to assess the outcomes of this group that is considered obese with new criteria but not by using BMI criteria.
BAPS (Bochasanwasi Akshar Purushottam Swaminarayan Sanstha) Atlanta. This is a magnificent Hindu spiritual center in Lilburn. No photos are allowed inside though there are several online (see below).
A Almallouhi et al. J Pediatr Gastroenterol Nutr. 2025 DOI: 10.1002/jpn3.70316. Clinical outcome of constipation as the presenting symptom in children with celiac disease
Background: “It is not clear if CeD prevalence is higher in children with refractory and chronic constipation or not.11–15 The current guidelines from the American Gastroenterological Association (AGA) and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) do not consider constipation an indication for CeD testing in the absence of suggestive family history, growth, or developmental delay.”
Methods: This was a retrospective study (1994-2024) of children (<18 years) who presented with constipation and then diagnosed with celiac disease (CeD). There were 248 children with CeD, 177 (71%) had biopsy-confirmed CeD, and 56 (23%) were diagnosed with serology-only criteria
Key findings:
My take:
It is unclear if having constipation increases the risk of celiac disease
Many children with celiac disease also have functional disorders like irritable bowel and constipation that often continue despite a gluten-free diet
RM Califf et al. N Engl J Med 2026;394:4-6. A Threat to Evidence-Based Vaccine Policy and Public Health Security at the FDA
This editorial by 12 former FDA commissioners of both Democratic and Republican administrations is sharply critical of recent policy changes at the FDA which threaten the supply of life-saving vaccines.
Here is an excerpt:
“The existing regulatory model builds public trust by encouraging open information exchange and rigorous, transparent scientific debate. Yet a memo sent last week to FDA staff will upend core policies governing vaccine development and updates…
The memo (available at https://www.biocentury.com/article/657740) was written by Vinay Prasad, director of the FDA’s Center for Biologics Evaluation and Research (CBER), who also serves as the agency’s chief scientific officer, chief medical officer, and acting head of CBER’s office of biostatistics, as well as overseeing the division responsible for vaccine review and approval. His memo characterizes the actions of FDA scientists who express concerns about agency processes or decisions to outside parties as “unethical” and “illegal.” It calls for scientific debates to be kept within the agency “until they are ready to be made public,” and instructs staff members who disagree with the new framework to “submit your resignation letters.”..
If enacted, the framework would impede the ability to update vaccines to keep up with the natural evolution of respiratory viruses or changes in the prevalence of bacterial serotypes…
The new framework rejects the agency’s long-standing reliance on “immunobridging” studies for well-understood vaccines with extensive safety data. Using this approach, once a reliable correlation with effectiveness has been established, a vaccine’s ability to stimulate the immune system to produce protective antibodies can serve as a surrogate for its efficacy in helping patients avoid infections and complications from rapidly evolving viruses such as SARS-CoV-2 and influenza. Because these viruses change frequently, repeating large-scale efficacy trials for every new seasonal strain is not feasible within the time needed to update the vaccines…
Abandoning the existing methods won’t “elevate vaccine science,” as the memo asserts. It will subject vaccines to a substantially higher and more subjective approval bar. The proposed measures will slow the replacement of older products with better ones and will create potentially prohibitive expenses for new market entrants…Moreover, insisting on long, expensive outcomes studies for every updated formulation would delay the arrival of better-matched vaccines when new outbreaks emerge or when additional groups of patients could benefit…
The new approach would also evade public transparency, including long-standing statutory and regulatory mechanisms that enable disagreements about benefit–risk balance, clinical trial end points, trial design, and data analysis to be aired in public…
The benefits and risks of many established vaccines are well understood, and imposing the new approval requirements without meaningful new evidence could make it impossible to keep up with evolving infectious threats.
The memo asserts, incorrectly, that “we do not have reliable data” on the benefits of Covid vaccination in children. Reasonable scientists should engage in open debate about how best to shape recommendations for children at lower risk for Covid-19, but substantial evidence shows that vaccination can reduce the risk of severe disease and hospitalization in many children and adolescents…
Americans’ safety depends on a culture in which evidence is reviewed openly and staff can surface concerns, challenge leadership, and engage with external scientists without fear of reprisal.
In a nearby neighborhood, my wife and I went walking and came across a “free art” stand which looked similar to a “free little library” stand. We picked out this small piece (about 5 inches on each side).
gutsandgrowth 