Author Archives: gutsandgrowth

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About gutsandgrowth

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.

What Caught My Eye in a Recent Anti-IL23 Commentary

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This recent commentary on the all-subcutaneous induction and maintenance treatment with guselkumab, an anti-IL23 agent, reviewed the GRAVITI study. Related post: Guselkumab for Crohn’s Disease: Pivotal GRAVITI Study

However, what captured my attention was the last sentence: “The convenience of subcutaneous induction enhances patient friendliness, positioning guselkumab as a strong market contender. Could an oral anti–IL-23 formulation be the next game changer?14“

“Johnson & Johnson (NYSE: JNJ) today announced positive topline results from ANTHEM-UC, a Phase 2b study of icotrokinra (JNJ-2113), the first investigational targeted oral peptide that selectively blocks the IL-23 receptor, in adults with moderately to severely active ulcerative colitis (UC)…

In the ANTHEM-UC study (n=252), three doses of once daily icotrokinra were tested with all meeting the primary endpoint of clinical response at Week 12. A response rate of 63.5% for patients treated with the highest dose of icotrokinra was achieved at Week 12 versus 27% for placebo (p<0.001). Further, 30.2% of patients treated with the highest dose of icotrokinra demonstrated clinical remission at Week 12 versus 11.1% of patients who received placebo (p<0.01). Remission and response rates continued to improve through Week 28.

  • Clinical response is defined as decrease from baseline in the modified Mayo score by greater than or equal to (>=) 30 percent (%) and >=2 points, with either a >=1-point decrease from baseline in the rectal bleeding subscore or a rectal bleeding subscore of 0 or 1.
  • Clinical remission is defined as a Mayo stool frequency subscore of 0 or 1 and not increased from induction baseline, a Mayo rectal bleeding subscore of 0, and a Mayo endoscopy subscore of 0 or 1 with no friability present on the endoscopy.”

My take: It would be terrific for patients with inflammatory bowel disease (and other immune-mediated diseases) to have another excellent oral therapy. A prior study of plaque psoriasis indicated that an oral IL-23 medication is feasible (Related post: In Trials: An Oral IL-23 Antagonist Peptide).

Related joke (regarding “caught my eye” in the title of this post):

A man who lived in a block of apartments thought it was raining and put his head out the window to check.  As he did so a glass eye fell into his hand. He looked up to see where it came from in time to see a young woman looking down. “Is this yours?” he asked.

She said, “Yes, could you bring it up?” and the man agreed. On arrival she was profuse in her thanks and offered the man a drink. Shortly afterwards she said, “I’m about to have dinner.  There’s plenty; would you like to join me?” He readily accepted her offer and both enjoyed a lovely meal. As the evening was drawing to a close the lady said, “I’ve had a marvelous evening.  Would you like to stay the night?”  The man hesitated then said, “Do you act like this with every man you meet?”

“No,” she replied, “only those who catch my eye.”

The Manneporte by Claude Monet (at the Metropolitan Museum of Art)

Global Evidence of Gastric Cancer Prevention with Helicobacter pylori Eradication

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Several recent articles have confirmed the benefits of H pylori eradication on reducing the risk of gastric cancer. This is in both Western and Eastern populations.

In this retrospective study from Nordic countries (Denmark, Sweden, Norway, Finland, and Iceland), researchers followed outcomes among ~700,000 people treated for H. pylori infection. The incidence of gastric adenocarcinoma was twice that of the general population in the first 5 years after treatment, likely reflecting H. pylori–related carcinogenesis that already was underway, but after 11 years, the incidence fell to that of the general population and remained there.

Discussion points:

  • The results of this study from 5 entire Western countries are in line with systematic reviews from Asian populations, indicating that H pylori eradication reduces the risk of gastric cancer
  • In addition, it has been proposed that eradication of H pylori might increase the risk of esophageal adenocarcinoma, but our recent study based on the NordHePEP found no such increase (Ref: Gastroenterology. 2024; 167:485-492.e3)

In this population-based study with more than 900,000 individuals, gastric cancer incidence and mortality rates were significantly lower in H pylori-treated individuals than in the general population.

In this meta-analysis of 11 randomized trials and 13 cohort studies researchers compared outcomes in treated and untreated H. pylori–positive adults. In both groups of studies, gastric cancer incidence was 40% lower in people who underwent H. pylori eradication. All but two of these studies were from eastern Asia.

 “In 2025, the IARC Working Group has issued a new report reaffirming H pylori eradication as a globally actionable and cost-effective intervention for the primary prevention of GC.18…Also, addressing the global public health challenge of antibiotic resistance remains essential, necessitating the development of susceptibility-guided or empirically optimized regimens tailored to local resistance patterns.

My take (borrowed from the commentary): “Despite the challenges, collectively, the emerging evidence from diverse populations reinforces the significant benefits of H pylori eradication in reducing GC incidence and mortality. These findings continuously support that H pylori eradication remains an effective preventive strategy across demographic settings, highlighting its relevance as a critical public health measure globally.”

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IBS Impact: Survey Reveals Daily Life Struggles

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AGA GastroNews, AGA IBS in America survey reveals IBS major burden despite advances in treatment (8/7/25):

Methods: The Harris Poll on behalf of AGA in 2024, among 2,013 U.S. adults age 18+ who have been diagnosed by a health care provider with IBS-C (1,005) or IBS-D (1,008). In addition, U.S. health care provider research was conducted online among 600 health care providers including gastroenterologists (n=200), primary care physicians (PCPs, n=200), gastroenterology nurse practitioners (NP)/physician assistants (PA) (n=100), and PCP NP/PAs (n=100)

Key findings:

  • IBS symptoms interfere with patients’ productivity at work/school for nearly 11 days per month on average
  • IBS symptoms disrupt personal activities eight days per month on average
  • 69% say their symptoms make them feel like they’re not “normal”
  • 77% avoid situations where bathroom access is limited.
  • 72% find it difficult to plan activities due to unpredictable symptoms.
  • 72% stay home more often because of their symptoms

My take: This sample of patients with IBS likely has more severe symptoms than a more general population of patients with IBS. Nevertheless, it highlights the impact of IBS symptoms on daily living.

Link: AGA IBS Toolkit

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Westminster Abbey, London


Is a High Protein Diet Beneficial and Safe?

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There has been a lot of hype about the benefits of a high protein diet. In a recent substack article (8/31/25) , Eric Topol reviews the data on this (for adults).

Here’s the link:Our Preoccupation With Protein Intake

Key points:

  • “The pervasive call for higher protein intake stems from the assertion that people are not getting adequate amounts in their diet, namely the 0.8 g/kg/day recommend by the National Academy of Medicine and the World Health Organization….
  • Regarding the need to increase protein intake 2-3 fold per day, Stuart Phillips, a leading expert on protein, energy, and building muscle mass, who is a professor at McMaster University in Canada, said “It’s baloney. But there’s a generation, particularly young men, and now an increasing number of young women, who are absolutely brainwashed by what they hear online”…there are no data to support more than 1.6 g/kg/day of protein intake.

Safety concerns:

  • “There are many observational studies that have raised the safety concerns for high-protein intake, particularly derived from animal protein, for increased risk of type 2 diabetes, cardiovascular disease, and higher all-cause mortality. A prospective study of ~44,000 women in Sweden followed for 15.7 years found an association of high-protein diet with heightened cardiovascular risk.”
  • A “high protein intake is dangerous for people with kidney disease, present in 1 of 7 adults, but 9 of 10 people with reduced kidney function are unaware of it.”

My take (borrowed from Dr. Topol): “The body of evidence about protein does not provide support [for] very high protein intake, certainly not in excess of 1.6 g/kg/day…there is no way to store protein in the body…Resistance training is the principal driver for building muscle mass and strength, not high protein intake.” While this article focuses on adults, the premise is similar in children; though, on a per kilogram basis, children need modestly higher amounts. (Reference: JL Hudson et al. Nutrients. 2021 May 5;13(5):1554. Dietary Protein Requirements in Children: Methods for Consideration)

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How Often Esophageal Coins Pass Into the Stomach

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P Quitadomo et al. Am J Gastroenterol 2025; 120: 1388-1390. “Insert-Coin”: A Prospective Study of Coin Ingestion in Children of Southern Italy

Thanks to Ben Gold for this reference.

This prospective study from Naples, Italy examined children 0-14 yrs of age with a coin ingestion (n=807). Children with coins in the proximal esophagus underwent endoscopic removal within 4 hours whereas those with middle to lower esophageal coins had re-evaluation after 12 hours before removal.

Key findings:

  • 52 of 807 (6.4%) had a coin retained in the esophagus, the remainder were in the stomach or beyond
  • 20 of 52 (38%) were located in the middle to lower esophagus (10 in each)
  • 13 of 20 (65%) coins in the middle to lower esophagus had spontaneous gastric passage
  • The mean age of patients with gastric passage (72 months) was higher than those without passage (48 months)

My take: Only 6% of patients in this study who had a coin ingestion had esophageal retention of the coin. In addition, one-fourth of those with esophageal coins had spontaneous passage into the stomach. This occurred only with the mid-distal esophageal coins; in this subset it occurred in 65%. Thus, in those with mid-distal esophageal coins, watchful waiting for ~12 hrs may be beneficial for patients. The ultimate primary prevention of this problem may occur with more widespread adoption of electronic payments.

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Agnes Northrup of Louis Tiffany Studio,
Tiffany Garden Landscape Window (1912)
at The Metropolitan Museum of Art
Agnes Northrup of Louis Tiffany Studio,
Autumn Landscape  (1923) at The Metropolitan Museum of Art

“Are Marathons and Extreme Running Linked to Colon Cancer?”

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NY Times 8/19/25: Are Marathons and Extreme Running Linked to Colon Cancer?

An excerpt:

A small, preliminary study found that marathoners were much more likely to have precancerous growths. Experts aren’t sure why…

Dr. Cannon, an oncologist with Inova Schar Cancer in Fairfax, Va., launched a study, recruiting 100 marathon and ultramarathon runners aged 35 to 50 to undergo a colonoscopy.

The results were staggering. Almost half the participants had polyps, and 15 percent had advanced adenomas likely to become cancerous. The rate of advanced adenomas was much higher than that seen among adults in their late 40s in the general population, which ranges from 4.5 percent to 6 percent, according to recent studies.

The research was presented at an American Society of Clinical Oncology conference but has not yet been published in a medical journal…

Dr. David Rubin, chief of gastroenterology and director of the Inflammatory Bowel Disease Center at the University of Chicago, said the study was important but limited. It lacked a control arm consisting of similar young adults who were not long-distance runners, he noted, and the family histories of colon cancer among the marathoners were not entirely known…

Runners often develop gastrointestinal symptoms that they dismiss as benign — so-called runner’s trots, for example. The symptoms can be caused by ischemic colitis, a condition that develops when blood flow to the colon is temporarily reduced as it is redirected to muscles in other parts of body (like a runner’s legs).

My take: While this is a small study, it indicates that extreme runners could have an increased risk of colonic polyps and cancer. If there are symptoms (especially rectal bleeding and weight loss), a low threshold for further evaluation is needed.

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View of Statue of Liberty from Governor’s Island

IBD Management in Pregnancy: Global Consensus

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U Mahadevan et al. Clinical Gastroenterology and Hepatology 2025 (published ahead of print). Open Access! Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease

Addendum -updated reference: U Mahadevan et al. Clinical Gastroenterology and Hepatology 2025; 23: S1-S60. Open Access! Global Consensus Statement on the Management of Pregnancy in Inflammatory Bowel Disease

This is a 60 page open access article. Table 1 lists 34 “GRADE” statements and Table 2 lists 35 consensus statements. This article is also jointly published in the following:

  • Gut
  • Am J Gastroenterol
  • Inflammatory Bowel Diseases
  • Journal of Crohn’s and Colitis
  • Aliment Pharmacol Ther

For Moms:

For Babies:

My take: This is a useful reference –mainly helpful for gastroenterologists rather than pediatric providers.

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The Best Way to Judge Pediatric Poo

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J Orozco et al. Am J Gastroenterol 2025; 120: 1381-1387. Comparison of the Bristol Stool Scale and Modified Version for Children: Use by Providers vs Children

Thanks to Ben Gold for this reference.

Background: The modified Bristol Stool Form Scale for Children (mBSFS-C) removes #3 and #5 from the Bristol Stool Form Scale (BSFS), leaving only one normal image and shortening the options from seven to five.

Methods: Pediatric gastroenterology providers  (21 faculty, 11 fellows, 3 nurse practitioners)  and 200 children/families rated the same 35 stool photographs, reflecting diverse stool forms, using both scales. The order of photograph presentation and scale use were randomized.

Modified Bristol Stool Scale
Bristol Stool Chart

Key findings:

  •  Of 1,225 provider ratings using the mBSFS-C, 90.0% agreed with the provider’s modal ratings vs 77.8% using the BSFS.
  • Of 7,000 child ratings using the mBSFS-C, 84.6% agreed with the children’s modal ratings vs 71.8% using the BSFS.
  • Using providers’ modal ratings as the reference, all mBSFS-C photograph modal ratings matched between children and providers (35/35 photographs) whereas only 86% (30/35 photographs) matched with the BSFS.

Discussion:

  • “Unique and new in this study is the direct head-to-head comparison of the 2 scales (BSFS, mBSFS-C) when used by pediatric gastroenterology providers and children. Both the BSFS and mBSFS-C demonstrated excellent reliability…modal rating agreement was significantly poorer for the BSFS than for the mBSFS-C.”
  • “Almost 20% of the time expert raters using the BSFS (vs. 8% with the mBSFS-C) deemed a stool to be a different clinical delineation than that selected by the majority of their peers.”

Related editorial: Peter Lu, The American Journal of Gastroenterology 120(6):p 1267, June 2025. Is It Time to Scale Down the Bristol?

My take: The modified BSFS is easier and better. This study indicates it should be widely used for children but probably for adults too. As Dr. Lu’s editorial notes, “aren’t adults just big children?”

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“The Broken Promises of Profit-Driven Medicine”

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N Tomes. NEJM 2025; 393: 521-524. A Gilded Age for Patients? The Broken Promises of Profit-Driven Medicine

This article (one of several in a series) describes the development of the current corporate-centered health care system over the past 100 years and the drawbacks.

An excerpt:

Between the 1920s and the 1960s, the American medical profession adopted a new doctor-controlled business model of care delivery, dependent on continual investment in new drugs, technologies, and procedures. That model created the profit opportunities that enticed corporate stakeholders to invest in health care in the 1970s and 1980s. But as the corporate presence increased, physicians lost control of their business model; the “tail” of financialization began wagging the “dog” of medical practice. That shift coincided with corporate cooptation of the language of consumerism to justify these changes as in patients’ best interests. In the process, physicians and patients lost economic autonomy over health care choices…

Insurance plans let doctors and hospitals set prices, facilitating more investment in the capital-intensive technologies equated with higher-quality care. But that dynamic also created an upward spiral of costs…These problems led to a second transformative movement: the federal government’s entry into the health insurance business, with the creation of Medicare and Medicaid, which also let doctors and hospitals set prices. This… aimed to relieve Americans of the duty of financing the medical system themselves, bringing in third parties to help. Enrollees in the new plans got more coverage but only on the terms set by those parties; uninsured people had to manage on their own. Meanwhile, the cycle of rising costs continued unabated…

Medical entrepreneurs believed that applying market discipline to health care would produce the right combination of innovation, efficiency, and cost–benefit balance to ensure better care for patients while profiting investors…

While adopting some consumer-industry practices, corporate health care players strove to avoid others, such as direct price competition. Policy efforts to rein in costs stressed the need for price transparency: consumer–patients needed to “shop” more critically for the cheapest care. In this spirit, political conservatives promoted “consumer-driven” health care. But such schemes foundered on the reality that many insurance plans gave patients little flexibility to price-shop for care…

Many powerful health care industry stakeholders still believe allowing corporate interests freer rein will produce that “golden age for patients.” The health care economy’s fragility suggests otherwise…When they [hospitals] pivoted from profitable surgeries to unprofitable Covid care, they needed massive infusions of government funding to survive.  Similarly, recent shortages of essential but low-profit drugs, including chemotherapy agents and insulin, reveal the limits of the pharmaceutical industry’s profit-oriented approach to essential drug production…

No market solution has arisen for the most critical determinant of poor health and health care outcomes in the United States: extreme income inequality. Countless studies indicate that poverty is the most important health risk factor that Americans face…little profit can be made by preventing or treating poverty-induced illnesses.

U.S. health care needs a new business model…only more collective physician and patient action will help medicine find a more equitable, sustainable model…Many people will suffer if the system collapses completely, but perhaps a more sustainable health care system can be built from the rubble.

My take: This analysis of the U.S. healthcare system, like many others, is analogous to getting the license plate of the truck that ran you over. At this time, there is little prospect of stopping the truck.

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Stone Mountain, Ga from the Cherokee Trail

New Data on the Reliability of the No-Biopsy Diagnosis in Pediatric Celiac Disease

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Chang D, Wong M, Camila Cardenas M, et al. Pediatrics. 2025;156(3):e2025070897. Positive Predictive Value of Tissue Transglutaminase IgA for Celiac Disease.

Background:For a no-biopsy celiac diagnosis, “the [ESPGHAN] criteria were revised in 2020, to specify that only a highly positive tTG IgA greater than or equal to 10× ULN and a positive EMA on a second blood sample are sufficient to diagnose celiac disease, obviating the need for HLA testing or symptoms.” NASPGHAN “has yet to adopt similar serologic criteria for diagnosing celiac disease. A clinical report in 2016 continued to recommend a confirmatory biopsy in all suspected cases of celiac disease. This recommendation cited concerns of interassay variability.”

Methods: This was a retrospective, multicenter North American cohort study of children (<18 years) with an elevated tTG IgA within 6 months of an esophagogastroduodenoscopy between January 2016 and December 2021. Biopsy-confirmed celiac disease was determined by the presence of intraepithelial lymphocytosis and villous atrophy. The primary outcomes were the PPV of an elevated tTG IgA and tTG IgA greater than or equal to 10 times the upper limit of normal (10× ULN).

The study identified 4019 children with the following characteristics: 63.3% female; 9% type 1 diabetes, and 2% Down syndrome

Key findings:

  • Histologic findings in the entire cohort were consistent with celiac disease for 3321 children (PPV = 82.6%)
  • Among the 1739/4019 (43.2%) children with tTG IgA greater than or equal
    to 10× ULN, 1651 had biopsy-confirmed celiac disease (PPV10× = 94.9%). Five percent (88/1739) of children did not have histologic findings of celiac disease, including 41/1739 (2%) with normal histology
  • EMA only marginally improved specificity as 76% of children without celiac disease and tTG IgA greater than or equal to 10× ULN had a positive EMA, albeit on the same sample. There was variations across providers, practices, and countries, which resulted in EMA not being performed in all cases or tested on the same blood sample as the tTG IgA
  • Assays performed worse in children with type 1 diabetes (PPV10× 89%) than that in those without T1DM (95.7%)
  • Of those with esophageal biopsies, 175/2980 (6%) had at least 15 eos/hpf in at least 1 esophageal biopsy
  • Of those with gastric biopsies, 912/3534 (25.8%) had histologic gastritis, including 1.4% (51/3534) with evidence of Helicobacter infection (n (49 cases of H pylori and 2 cases of H heilmannii)

My take: This study indicates that the no-biopsy diagnostic approach for celiac disease may need to be reconsidered. Though, it is likely that the no-biopsy approach would have had a higher PPV if the guidelines were actually followed (eg. separate EMA confirmatory sample). The values in this study show a much lower PPV than prior studies (96% in those without T1DM). In addition, among the 4% without celiac disease (potential celiac disease), about half of them would likely progress to celiac disease and could potentially benefit from a gluten free diet. Thus, up to 2%of patients, based on this study, would probably be harmed by being placed on a gluten free diet.

Another point to reiterate based on this study, diagnostic confirmation by a specialist prior to dietary changes is recommended. Increasingly, patients are referred after starting a gluten free diet.

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Brooklyn Botanic Gardens