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.

Update on Upper GI Bleeding Recommendations

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DK Mullady et al. Gastroenterol 2020; 159: 1120-1128. AGA Clinical Practice Update on Endoscopic Therapies for Non-Variceal Upper Gastrointestinal Bleeding: Expert Review

Listed below are the 10 ‘Best Practice Advice’ recommendations. I think the acknowledgement that “hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement” (#7) is very useful.

“Best Practice Advice:”
  • Endoscopic therapy should achieve hemostasis in the majority of patients with NVUGIB.
    • This may include clips, thermal (heater probes, bipolar/multipolar catheters, hemostatic forceps), diluted epinephrine injection, and hemostatic spray
  • Initial management of the patient with NVUGIB should focus on resuscitation, triage, and preparation for upper endoscopy. After stabilization, patients with NVUGIB should undergo endoscopy with endoscopic treatment of sites with active bleeding or high-risk stigmata for rebleeding.
  • Endoscopists should be familiar with the indications, efficacy, and limitations of currently available tools and techniques for endoscopic hemostasis, and be comfortable applying conventional thermal therapy and placing hemoclips.
  • Monopolar hemostatic forceps with low-voltage coagulation can be an effective alternative to other mechanical and thermal treatments for NVUGIB, particularly for ulcers in difficult locations or those with a rigid and fibrotic base.
  • Hemostasis using an over-the-scope clip should be considered in select patients with NVUGIB, in whom conventional electrosurgical coagulation and hemostatic clips are unsuccessful or predicted to be ineffective.
  • Hemostatic powders are a noncontact endoscopic option that may be considered in cases of massive bleeding with poor visualization, for salvage therapy, and for diffuse bleeding from malignancy.
  • Hemostatic powder should be preferentially used as a rescue therapy and not for primary hemostasis, except in cases of malignant bleeding or massive bleeding with inability to perform thermal therapy or hemoclip placement.
  • Endoscopists should understand the risk of bleeding from therapeutic endoscopic interventions (eg, endoluminal resection and endoscopic sphincterotomy) and be familiar with the endoscopic tools and techniques to treat intraprocedural bleeding and minimize the risk of delayed bleeding.
  • In patients with endoscopically refractory NVUGIB, the etiology of bleeding (peptic ulcer disease, unknown source, post surgical); patient factors (hemodynamic instability, coagulopathy, multi-organ failure, surgical history); risk of rebleeding; and potential adverse events should be taken into consideration when deciding on a case-by-case basis between transcatheter arterial embolization and surgery.
  • Prophylactic transcatheter arterial embolization of high-risk ulcers after successful endoscopic therapy is not encouraged.

Related blog posts:

Operation Warp Speed Strategy

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M Slaoui, M Hepburn. NEJM 2020; 383: 1701-1703. Full text: Developing Safe and Effective Covid Vaccines — Operation Warp Speed’s Strategy and Approach

As an aside, I have always thought that the name, “Operation Warp Speed,” sounded like a line from the movie Spaceballs.

This article provides insight into the strategy for “Operation Warp Speed” (OWS). An excerpt:

OWS’s strategy relies on a few key principles. First, we sought to build a diverse project portfolio that includes two vaccine candidates based on each of the four platform technologies…In addition, advancing eight vaccines in parallel will increase the chances of delivering 300 million doses in the first half of 2021…

Of the eight vaccines in OWS’s portfolio, six have been announced and partnerships executed with the companies: Moderna and Pfizer/BioNTech (both mRNA), AstraZeneca and Janssen (both replication-defective live-vector), and Novavax and Sanofi/GSK (both recombinant-subunit-adjuvanted protein). These candidates cover three of the four platform technologies and are currently in clinical trials. The remaining two candidates will enter trials soon...

No scientific enterprise could guarantee success by January 2021, but the strategic decisions and choices we’ve made, the support the government has provided, and the accomplishments to date make us optimistic that we will succeed in this unprecedented endeavor.

Related article:

NY Times (11/9/20): Pfizer’s Early Data Shows Vaccine Is More Than 90% Effective

Small Study: Kiwi For Constipation

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Healio Gastroenterology: Kiwi fruit effective, well tolerated in treating chronic constipation

From a randomized (Virtual) ACG 2020 study from Samuel W. Chey and colleagues (University of Michigan), n=79 adults:

  • “All three treatments improved complete spontaneous bowel movement (P .003). Prunes demonstrated the largest magnitude of response at 67% vs. 64% for psyllium vs. 45% for Kiwi fruit”
  • “The highest proportion of participants – 68% – reported treatment satisfaction with kiwifruit while similar proportions of those receiving prunes and psyllium – 48% – reported satisfaction”
  • “The kiwi group had the lowest proportion of participants reporting treatment dissatisfaction at 7%….Participants receiving prunes and psyllium were more likely to report abdominal pain and bloating than those receiving kiwi”

How Primary Sclerosing Cholangitis Alters Outcomes in Inflammatory Bowel Disease

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PJ Trivedi et al. Gastroenterol 2020; 159: 915-928. Effects of Primary Sclerosing Cholangitis on Risks of Cancer and Death in People With Inflammatory Bowel Disease, Based on Sex, Race, and Age

Methods: The authors linked prospectively collected data from national health care registries maintained for all adults in England on hospital attendances, imaging and endoscopic evaluations, surgical procedures, cancer, and deaths.

Key findings:

  • Over 10 years, we identified 284,560 incident cases of IBD nationwide; of these, 2588 patients developed PSC. This study excluded patients <18 years of age.
  • Development of PSC was associated with increased risk of death and CRC (hazard ratios [HRs], 3.20 and 2.43, respectively; P < .001) and a lower median age at CRC diagnosis (59 y vs 69 y without PSC; P < .001)
  • Compared to patients with IBD alone, patients with PSC-IBD had a 4-fold higher risk of CRC if they received a diagnosis of IBD at an age younger than 40 years
  • Development of PSC also increased risks of cholangiocarcinoma (HR, 28.46), hepatocellular carcinoma (HR, 21.00), pancreatic cancer (HR, 5.26), and gallbladder cancer (HR, 9.19) ( P < .001 for all)
  • The greatest difference in mortality between the PSC-IBD alone group vs the IBD alone group was for patients younger than 40 years
  • Patients with PSC-UC had >40% risk of colonic resection compared to patients with IBD alone (aHR 1.65)

My take: This study shows the impact the added diagnosis of PSC has for patients with IBD. One of the limitations in assessing outcomes is determining whether someone with IBD has PSC as there are a lot of patients with IBD who have asymptomatic changes in their biliary tree.

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Should We Be Screening for Eating Disorders in Teenagers with Constipation?

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HB Murray et al. Clin Gastroenterol Hepatol 2020; 18: 2471-2478. Frequency of Eating Disorder Pathology Among Patients With Chronic Constipation and Contribution of Gastrointestinal-Specific Anxiety

Key findings:

  • In an analysis (n= 279 adults, 70% female, average age 47 years) of patients with chronic constipation at a tertiary center who were referred for anorectal manometry, 19% had symptoms consistent with an eating disorder; this assessment was based on the Eating Attitudes Test (EAT-26).
  • “Gastrointestinal-specific anxiety fully mediated the relationship between the severity of ED pathology and constipation (standardized β, 0.11–0.16; P = .026–.024).”

The authors note that screening for eating disorders “is of particular importance before prescribing dietary interventions.”

My take: While this was a study with adults, it is likely that chronic constipation may be a presenting feature of an eating disorder in teenagers as well.

“Surprise Billing for Colonoscopy: The Scope of the Problem”

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JM Scheiman et al. Annals of Internal Medicine. 2020; https://doi.org/10.7326/M20-2928. Surprise Billing for Colonoscopy: The Scope of the Problem

Background: “Federal law eliminates consumer cost sharing for multiple methods of colorectal cancer screening, including colonoscopy when done by an in-network provider. However, some patients having screening incur considerable out-of-pocket costs because out-of-network bills are not included in federal mandates. “Surprise billing” articles are widespread in the research literature and lay press . To date, the frequency of unexpected patient costs for screening colonoscopy have yet to be rigorously quantified.”

This study with ~983,000 procedures, which was conducted between 2012-2017, shows that it is common to get additional charges from a screening colonoscopy (which is supposed to be covered). Despite using an in-network physician, these charges can be due to “out-of-network” costs from anesthesia or pathology. This can also occur when anesthesia bills the colonoscopy as a diagnostic procedure rather than as a screening procedure.

From Annals of Internal Medicine Twitter Feed

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Complications More Common If Language Barrier

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Abstract: Association Between Parent Comfort With English and Adverse Events Among Hospitalized Children

Key finding:  Children of parents expressing LCE (limited comfort with English) had 2.1 higher odds of adverse events than children of parents who expressed comfort with English, after controlling for other factors.

Related blog post: No Habla Appendicitis

Nutrition Pearls -Fiber in Short Bowel and Good Growth with Cystic Fibrosis

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One useful resource for NASPGHAN members (NASPGHAN Nutrition Pearls) has been the short monthly nutrition pearl videos (about 10 of them so far). Here are some pointers from the most recent of these.

In October: Fiber for Short Bowel Syndrome –Beneficial for those with a colon in continuity:

Commercial products with limited data supporting use in short bowel syndrome
All of the fiber products are fermented in colon and may be beneficial. Highlighted products are more likely to help with stool consistency (thickening).

In September: Growth in Cystic Fibrosis

Related blog posts for Short Bowel Syndrome:

Related blog posts for Cystic Fibrosis:

Ustekinumab Effectiveness for Ulcerative Colitis Over Two Years

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R Pannacionne et al. AP&T. 2020; https://doi.org/10.1111/apt.16119. Full text link: Ustekinumab is effective and safe for ulcerative colitis through 2 years of maintenance therapy

Methods: Overall, 399 (adult) “responders to intravenous ustekinumab induction and who were randomised to maintenance therapy were treated in the long‐term extension (115 received subcutaneous placebo, 141 received ustekinumab 90 mg every 12 weeks [q12w], and 143 received ustekinumab 90 mg q8w). Placebo treatment was discontinued at unblinding after week 44”

Key Findings:

  • Symptomatic remission rates (stool frequency = 0/1; rectal bleeding = 0) at week 92 were, 64.5% and 67.6% in the ustekinumab q12w and q8w groups, respectively ((Intent-to-treat population).
  • At week 44 of maintenance, measures of UC disease activity (eg Mayo scores) were generally comparable among patients randomised to ustekinumab q12w and q8w with 46.1% and 52.4% in clinical remission and 56.7% and 61.5% with endoscopic improvement respectively
  • Among randomised patients treated in the long‐term extension, 78.7% and 83.2% of patients receiving q12w and q8w, respectively, attained symptomatic remission at week 92; >95% of patients in symptomatic remission at week 92 were corticosteroid‐free
  • No new safety signals were observed
Steroid-free Remission (Intent-to-treat population)

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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

Achalasia -More Complexity to Pathophysiology?

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RK Mittal et al. Gastroenterol 2020; 159: 864-72. Three-Dimensional Pressure Profile of the Lower Esophageal Sphincter and Crural Diaphragm in Patients with Achalasia Esophagus

This prospective study combined 3-dimensional high-resolution manometry (3D-HRM) with detailed analysis of computed tomography images to study the EGJ (esophagogastric junction) in patients with achalasia (n=12) and healthy controls (n=10). Key finding: Besides LES, the 3D pressure profile of the EGJ can indicate anatomic and functional abnormalities of the crural diaphragm muscle in patients with achalasia esophagus

Full text editorial: DA Katzka, M Fox. Gastroenterol 2020: 159: 821- 23. Achalasia: When a Simple Disease Becomes Complex

“In this edition of Gastroenterology, researchers led by Ravi Mittal …demonstrated an asymmetric, extrinsic CD (crural diaphragm) component to EGJ pressure superimposed on the intrinsic LES.”

Related blog posts: