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.
Roughly 15 million people — six percent of adults in the United States — have metabolic dysfunction-associated steatohepatitis, known as MASH. Rates of the disease are rising…
Wegovy, which is a weekly injection, is now approved for adults with MASH and moderate-to-advanced levels of fibrosis, or excessive scar tissue in the liver. The drug is not intended for people with cirrhosis…
Wegovy will be a welcome addition to the options doctors can prescribe — as long as their patients can access them. The drug carries a list price of over $1,300 a month, although most people do not pay that full amount. Many people have lost insurance coverage for weight-loss drugs, as plans struggle to keep up with the costs.
Related review article:G Targher et al. NEJM 2025; 393: 683-698. Metabolic Dysfunction–Associated Steatotic Liver Disease. This review article succinctly covers the epidemiology, manifestations, disease progression and pivotal pharmacologic advances.
“A team of researchers found evidence of shady organizations churning out fake or low-quality studies on an industrial scale. And their output is rising fast, threatening the integrity of many fields…“If these trends are not stopped, science is going to be destroyed,” said Luís A. Nunes Amaral, a data scientist at Northwestern University and an author of the study”
““Science relies on trusting what others did, so you do not have to repeat everything,” Dr. Amaral said….By the 2010s, journal editors and watchdog organizations were warning that this trust was under threat. They flagged a growing number of papers with fabricated data and doctored images. In the years that followed, the factors driving this increase grew more intense.”
“As more graduate students were trained in labs, the competition for a limited number of research jobs sharpened. High-profile papers became essential for success, not just for landing a job, but also for getting promotions and grants. Academic publishers have responded to the demand by opening thousands of new scientific journals every year…”
“Organizations known as paper mills are now turning scientific fraud into a lucrative business. Scientists eager to pad out their resumes can pay hundreds to thousands of dollars to be named as an author of a paper that they had nothing to do with…paper mills often use artificial intelligence to alter the text they lift from other papers…”
“The papers that Dr. Amaral and his colleagues could study came to light only because of the work of independent sleuths. To estimate how many paper mill papers have yet to be exposed, Dr. Amaral’s team created a statistical model that accurately predicted the rate at which suspicious papers surfaced. They estimate that the number of paper mill products may be 100 times greater than the ones they have identified…”
“In their new study, they calculated that the number of suspicious new papers appearing each year was doubling every 1.5 years. That’s far faster than the increase of scientific papers overall, which is doubling every 15 years.”
““We need to stop making it profitable to game the system.”
My take: This problem has preceded the widespread use of AI, although Al makes it harder to detect. Unfortunately, fake scientific reporting appears to be worsening.
Related article: Jessica Steier NY Times 8/19/25: The Playbook Used to ‘Prove’ Vaccines Cause Autism This article details very specifically how David Geier (now appointed by RFK Jr to evaluate vaccines and autism) and his father have produced multiple flawed studies regarding vaccine safety. This commentary takes a particularly deep dive into one of his articles on the preservative thimerosol. She shows that the authors likely used p-hacking to identify “atypical autism” since there was not a significant association with autism, compared different time cohorts (the control group was from a period with different diagnostic criteria/lower rates of autism), did not include confounders, and supported their arguments with “personal citing.”
Some excerpts:
There have been some 70 studies since Mr. Wakefield’s looking for any link between vaccines and autism. Of these, 26 have linked vaccines to autism in some way, and 43 found no connection between vaccines and autism.
A whopping two-thirds of studies that claimed to have found a link were written by David and Mark Geier. These studies have been heavily criticized for using deceptive research techniques and flawed data.
Among the eight other studies that found a link, four were retracted for data manipulation, flawed methods or undisclosed conflicts of interest. Most of the authors have been involved in anti-vaccination campaigns and have had other papers retracted.
One such study that Mr. Kennedy referred to in his Senate confirmation hearing was published in a WordPress blog disguised as a journal and was funded by an anti-vaccine organization, among other problems.
Fortunately, independent scientists have conducted more than 40 high-quality studies since 1998 involving over 5.6 million people across seven countries. All found no connection between vaccines and autism. These studies were rigorously designed, were reviewed by independent peers and do not contain telltale signs of data manipulation, as the Geier studies do.
Recently Dr. Bezerra gave our group a terrific lecture. I have taken some notes and shared some of his slides. There may be inadvertent omissions and mistakes in my notes. In addition, Dr. Bezerra’s presentation included several lengthy animations which helped explain the basic science concepts. These are not included in this summary.
Prior to his presentation to our group, Dr. Bezerra’s accomplishments had been recognized with the Shwachman Award, the highest honor bestowed by our national pediatric GI organization NASPGHAN (NASPGHAN Awards 2025). On a personal note, Jorge was the first person to give me hands-on instruction with an endoscope and I have a great deal of admiration for his humility, thoughtfulness and scientific achievements.
Liver biopsy from patient with BA showing bile duct proliferation .Operative cholangiograms from a patient with normal anatomy and one with BA that shows contrast extravasation without patent biliary tract
Key points:
Cytomegalovirus (CMV) is frequently associated with biliary atresia (BA). Treatment of CMV when detected may improve outcomes
Hepatoportoenterostomy (HPE) (aka Kasai procedure) is effective in about half of patients. The remainder develop complications that include recurrent cholangitis, portal hypertension, and cirrhosis which may lead to the need for liver transplantation
10-year survival rates for liver transplantation are >85%.
Historical controls in red and new protocol in blue
The role of the microbiome is being explored as a factor in the predisposition to BA
Biliary atresia organoid studies: Biliary atresia organoids had decreased expression of genes related to EGF signaling and FGF2 signaling. When treated with EGF+FGF2, biliary atresia organoids expressed differentiation markers, which restored polarity (Reference: Hepatology 2022 Jan;75(1):89-103. doi: 10.1002/hep.32107. Biliary organoids uncover delayed epithelial development and barrier function in biliary atresia). Thus, these organoids can help understand the underlying pathogenesis and may lead to improved treatments
More recently, compared to normal liver organoids, the epithelium of BA organoids was fragmented and peribiliary glands (PBGs) were small, had abnormal intercellular junction (ZO1 expression), and expressed markers of epithelial-mesenchymal transition (EMT), with a prominent expression of TGF-β3. Upon TGF-β inhibition, EMT decreased in the diseased epithelium, the population of PBGs increased, and ZO1 expression improved. In vivo, TGF-β inhibition suppressed the BA phenotype and substantially decreased liver fibrosis in neonatal mice. Thus, the modulation of TGF-β-dependent EMT regulates bile duct epithelial development and influences the susceptibility of neonates to biliary injuries. (Reference: Nat Commun 2025 Jul 17;16:6575. doi: 10.1038/s41467-025-61442-5. Open Access! Cellular crosstalk mediated by TGF-β drives epithelial-mesenchymal transition in patient-derived multi-compartment biliary organoids)
RRV (rhesus rotavirus) can create an experimental model of BA in the mouse. In this mouse model, ILC2 cells (innate lymphoid cells in yellow) play a role in bile duct proliferation, possible attempt at recanalizing damaged bile ducts
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
Methods: This was a retrospective review of records of children (n=54, median age 9 years) who underwent MRI of spine between January 2021 and December 2023 for evaluation of refractory constipation (RC). RC was defined as constipation not responding to optimal conventional treatment for at least 3 months. Conventional treatment included—education, disimpaction (if required), osmotic and stimulant laxatives, timed‐toileting and biofeedback.
Key findings:
Thirteen children (24%) had an abnormal MRI. Findings included—syringomyelia‐8,sacral canal meningeal cyst‐2, filum terminale lipoma‐1,spina bifida occulta‐1 (SBO‐1), and Schmorl’s node‐1. None of these patients had a tethered cord
Only one patient with a Chiari malformation and syrinx required a neurosurgical intervention. The surgery did not improve his constipation
On a median follow‐up duration of 677 (range181–1240) days, constipation resolved in 48% (n = 26) of the entire cohort
There was no difference in the number of patients or time to constipation resolution between those with and without abnormal MRI respectively
My take: In children with refractory constipation who do not have abnormal cutaneous/abnormal neurological exam, an MRI is unlikely to be helpful.
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
Background: “Serious adverse events (SAEs) are unavoidable occurrences for those performing complex endoscopic interventions. These affect not only the patient (the first victim), but also possibly the proceduralist (the second victim). Second victim syndrome (SVS) was first described by Dr. Wu detailing the negative psychological effects of adverse patient events on physicians (Ref: Wu AW. Medical error: the second victim. BMJ. 2000;320(7237):726-727).”
Methods: Survey responses form “X” platform (n=195) were collected in 2023. Only responses from advanced endoscopists (defined as those who perform either endoscopic ultrasound or endoscopic retrograde cholangiopancreatography annually) and advanced endoscopy fellows were included.
Key findings:
Higher procedural volume (>1000/year) was associated with feelings of greater emotional preparedness for SAEs
Speaking with colleagues (53%), exercise (33%), discussions at conferences (17%) and meditation (8%) were rated as used and very or extremely helpful
Discussion Points: “Peer support programs have proven to be well received and highly utilized. Additionally, surgeons criticize the often-punitive handling of SAEs, and note that the tone and culture in the review process following an SAE dictates reduction or exacerbation of SVS.”
My take: When I have had a complication in a patient, speaking with colleagues has provided a lot of support. One book I have recommended to others is the following: Complications: A Surgeon’s Notes on an Imperfect Science by Atul Gawande.
I was recently listening to a radio program (On Point) about the beneficial effects of sunlight.
The program notes that the potential beneficial effects of sunlight are much greater than the risks. Increased sunlight has been associated with lower rates of death, as well as lower rates of cardiovascular disease and autoimmune conditions like multiple sclerosis, type 1 diabetes, and Crohn’s disease.
When dermatologists recommend avoiding sunlight, they may be focused on the risks but not the benefits (though this varies among individuals). In addition, despite the more than 5-fold rise of melanoma diagnosis (especially in wealthy communities), there has not been a change in the rate of deaths due to melanoma. Skin cancers associated with sun exposure are mainly basal cell tumors and squamous cell tumors. These non-melanoma skin cancers have excellent survival rates.
Here is a link: The Healing Power of Sunlight (48 minutes) The most important part of this is in the middle, starting around 20 minutes.
My take: It’s a good idea to avoid sunburns but getting sunshine is good for health.
Related article:
Environ Epidemiol 2025. 9(3):e401. doi: 10.1097/EE9.0000000000000401. The association between time spent outdoors during daylight and mortality among participants of the Adventist Health Study 2 Cohort. Conclusion: “Moderate time outdoors in daylight during warmer months could be associated with lower risks of all-cause, CVD, and noncancer non-CVD mortality”
From AGA Today (8/5/25): “Sterile Water is Unnecessary for Endoscopy”
GI and Hepatology News (8/4, Pass) reports a review suggests that “endoscopists can safely forgo sterile water in favor of tap, reducing both environmental and financial costs.” Researchers found that only two studies since 1975 “directly compared sterile and tap water use in endoscopy,” and “neither showed an increased risk of infection from tap water. In fact, some cultures from allegedly sterile water bottles grew pathogenic bacteria, while no patient complications were reported in either study.” Current guidelines “recommend sterile water for procedures involving mucosal penetration but acknowledge low-quality supporting evidence.” However, they pointed out that “these recommendations are based on outdated studies, some unrelated to GI endoscopy.” Furthermore, the “review estimates that the production and transportation of sterile water bottles contributes over 6,000 metric tons of emissions per year from US endoscopy units alone.” The review was published in Gastro Hep Advances.
“With a conservative estimate of using half of a 1-L sterile bottle for irrigation per endoscopy, 22 million yearly endoscopies in the US could result in an additional 6000 tons of eCO2.”
Economic Costs:
“A 1-L bottle of sterile water costs $3–$10. For an endoscopy unit performing 30 procedures daily and a conservative estimate of half a water bottle per case, the average monthly direct costs could be $1000–$3000”
Discussion:
“There is no direct supporting evidence for using sterile water during endoscopy…a Cochrane review show no difference in infection risk when using tap or sterile water to irrigate wounds…Similarly, there is no benefit in using sterile water for enteral feeds in immunosuppressed patients, and tap water enemas are routinely acceptable for colon cleansing before sigmoidoscopies in all patients, irrespective of immune status.
My take: Plastic water bottles in endoscopy centers contribute to health-care waste, climate change and increased costs.
E Van Daele et al.J Pediatr Gastroenterol Nutr. 2025;81:217–225. Aberrant microbiota signatures precede symptomdevelopment in infantile colic
My take: There has been an interest in altered microbiome and colic for a long time. Whether these alterations are causally-related to colic and whether there is a way to treat these alterations remains unclear.
AM Upton et al. J Pediatr Gastroenterol Nutr. 2025;81:212–216. The “maximum echogenicity” at the right portal vein: Biliary atresia versus Alagille syndrome
Background/Methods: One way clinicians can distinguish between biliary atresia and Alagille syndrome is with a positive “triangular cord sign.” This ultrasound finding refers to a thickened echogenicity at the anterior aspect of the right portal vein…the maximum echogenicity at the anterior aspect of the right portal vein (“maximum echogenicity” or “MxE”) was measured in a group of infants with cholestasis (Cohort 1, n=64) and in another group of infants with Alagille syndrome (Cohort 2, n=30).
Key findings:
“Thin echogenicity at the anterior aspect of the right portal vein may help distinguish between biliary atresia and Alagille syndrome…None of the 12 infants with biliary atresia in Cohort 1 had a MxE < 1.0 mm”
“A MxE < 1.0 mm could help identify Alagille syndrome. 2 of the 64 infants with cholestasis in Cohort 1 had a MxE < 1.0 mm. Both infants were eventually diagnosed with Alagille syndrome. In the Cohort 2 infants with Alagille syndrome, 16 of 30 infants had a MxE < 1.0 mm”
Infant with biliary atresia Infant with Alagille Syndrome
Discussion Point:
“Infants with Alagille syndrome can have smaller bile ducts which may be inapparent on invasive testing such as cholangiography. As a result, they may be presumptively diagnosed with biliary atresia and inappropriately treated with the Kasai portoenterostomy. Unfortunately, these infants have poorer outcomes compared to infants with Alagille syndrome who do not receive the Kasai portoenterostomy.” Thus, distinguishing Alagille from biliary atresia is very important.
My take: This study shows that MxE (a refinement of what has previously been called the triangular cord sign) on ultrasound may help distinguish biliary atresia from Alagille syndrome. As this is a single-center study, it will be important to determine if this ultrasound finding can be replicated in other centers and whether the finding is operator-dependent.
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
Methods: “GALAXI-2 and GALAXI-3 were identically designed, phase 3, randomised, double-blind, triple-dummy, treat-through trials with active and placebo comparators…1048 participants were randomly assigned, treated, and followed up until week 48, of whom 1021 participants were included in the primary analysis population: 508 (49·8%) in GALAXI-2 and 513 (50·2%) in GALAXI-3.” The studies enrolled adult patients with moderately to severely active Crohn’s disease.
Key findings:
Discussion points:
“Guselkumab treatment in participants with moderately to severely active Crohn’s disease was also evaluated in the GRAVITI study, which had a fully subcutaneous induction and maintenance treatment regimen. Clinical and endoscopic outcomes reported with subcutaneous guselkumab induction in the GRAVITI study were similar to those in the phase 3 GALAXI studies following intravenous guselkumab induction.”
“The incidence of adverse events with guselkumab during induction was low and similar to placebo.”
My take(borrowed from authors): In GALAXI-2 and GALAXI-3, both guselkumab dose regimens (each including intravenous induction and subcutaneous maintenance) were superior to placebo for short-term (week 12) and long-term (week 48) endpoints and both guselkumab dose regimens were also superior to ustekinumab
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