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.
E Stahl et al. Gastroenterol 2020; DOI:https://doi.org/10.1053/j.gastro.2020.04.063 Link: Collagenous Colitis Is Associated With HLA Signature and Shares Genetic Risks With Other Immune-Mediated Diseases
“In this largest genetic study of CC to date with histologically confirmed diagnosis, we strongly implicated the HLA locus and proposed potential non-HLA mechanisms in disease pathogenesis. We also detected a shared genetic risk between CC, celiac disease, CD, and UC.”
“Collagenous gastritis (CG) is a rare gastrointestinal disorder with fewer than 300 cases reported in the English-language literature.” If you have to manage one of these rare cases, here is a useful reference:
Key points:
- The prevalence of CG was 2.1/100,000 in children aged younger than 18 years
- The endoscopic and histologic findings remained pathologic in all the examined patients during a median follow-up of 4.4 years
- The serum levels of calprotectin and amyloid A were increased in 10/15 (67%) and 5/15 (33%) of the patients, respectively
A recent study (E Van de Vijver et al. Pediatrics 2020; 146: e20192235) shows a logical approach for testing children with diarrhea and abdominal pain.
Abstract and video abstract link: Test Strategies to Predict Inflammatory Bowel Disease Among Children With Nonbloody Diarrhea
Methods:
- Prospective cohort study: n=193, 6 to 18 years who underwent a standardized diagnostic workup.
- Patients with rectal bleeding or perianal disease were excluded because the presence of these findings prompted endoscopy regardless of their biomarkers.
- In addition to symptoms, objective measures included C-reactive protein (>10 mg/L), hemoglobin (<−2 SD for age and sex), and fecal calprotectin (≥250 μg/g).
Key findings:
- Twenty-two of 193 (11%) children had IBD
- “Triaging with a strategy that involves symptoms, blood markers, and calprotectin will result in 14 of 100 patients being exposed to endoscopy. Three of them will not have IBD, and no IBD-affected child will be missed.“
My take: The approach advocated by the authors of reserving a diagnostic endoscopy for children at high risk for IBD based on stool tests/blood tests in addition to symptoms has merit. I would add a couple caveats:
- In this population, I would recommend checking for celiac disease (eg. tissue tranglutaminase IgA antibody, serum IgA level)
- I think in individuals with ‘borderline’ elevations of calprotectin (50-250 μg/g), followup testing is needed and if remains persistently elevated, then ileocolonoscopy is likely warranted. (Calprotectin values in younger children tend to be higher -so this approach is best suited in children >5 years of age)
Related blog posts:
From The Doctor’s Company (an insurance company): Your Patient Is Logging on Now: The Risks and Benefits of Telehealth in the Future of Healthcare Thanks to John Pohl for sharing this link.
An excerpt:
Foreseeable Major Benefits
- Increases access to care for most patients, including many patients in rural locations, patients who struggle to cover the peripheral costs of an in-person visit (transportation, childcare, time away from work, etc.), and patients with chronic conditions.
- Enhances the ability to manage chronic conditions by making more frequent contact easier. This management is already supported by at-home devices that record blood pressure, blood sugar, and other essential data points.
- Reduces infection risks, not just for COVID-19, but for post-op patients, patients who are immunosuppressed, etc.
Other benefits: Promotes patient satisfaction, and scheduling -fewer no shows
Foreseeable Major Risks
- The remote exam’s inherent limitations mean physicians must know when to ask patients to come in to avoid missed diagnoses…[may be able to do] risk-stratifying patients with abdominal symptoms by, among other things, watching the patient jump up and down
- Increases cyber liability, especially when providers are seeing patients from a variety of devices in a variety of locations.
- Privacy issues come in high-tech forms: Is the video visit interface HIPAA compliant? And in low tech forms: Conversations may be interrupted by household members at either end.
- Decreases access to care for some patients: … many communities do not have sufficient internet bandwidth; some patients are prevented by a language barrier or lack of technological savvy from accessing a telemedicine portal.
- Reimbursement is uncertain: Pre-pandemic, “Low reimbursement for telehealth was viewed as a critical disincentive,” say the authors of an opinion piece in JAMA, because “Without payment, it would be difficult for clinicians to afford to provide the service, despite data from previous studies suggesting clinicians were broadly supportive about its use.”
Other drawbacks: Physician-patient relationship –glitches or delays in sound or video can impede the normal flow of conversation—a diagnostic risk, as well as a relational one.
W Zeng et al. JAMA Ophthalmol. Published online September 16, 2020. doi:10.1001/jamaophthalmol.2020.3906. full text Association of Daily Wear of Eyeglasses With Susceptibility to Coronavirus Disease 2019 Infection
Findings In this cohort of 276 patients hospitalized with COVID-19 in Suizhou, China, the proportion of daily wearers of eyeglasses was lower than that of the local population (5.8% vs 31.5%).
Meaning These findings suggest that daily wearers of eyeglasses may be less likely to be infected with COVID-19.
A recent retrospective study (RP Hirten et al. Inflamm Bowel Dis 2020; 26: 1050-1058. Anastomotic Ulcers After Ileocolic Resection for Crohn’s Disease Are Common and Predict Recurrence) showed that anastomotic ulcers occur in over half of Crohn’s disease patients after ileocolic resection and are associated with Crohn’s disease recurrence and are persistent.
Key findings:
- Anastomotic ulcers were present in 95 (52.2%) subjects. No factors were associated with anastomotic ulcer development.
- Anastomotic ulcers were associated with disease recurrence (adjusted hazard ratio [aHR] 3.64)
The associated editorial by Philllip Fleshner (pg 1059) identifies are a number of methodologic flaws, noting that less than 20% of all ileocolonic resections were included and marked variability in postoperative assessment (from 29 days to 2897 days).
My take: (borrowed from the editorial) the “findings should convince us that anastomotic ulcers do not represent ischemic changes but are rather a reflection of disease progression.” Prospective studies with standardized surveillance would be helpful.
This is a useful review -with helpful diagrams: Full text Ten Things Every Gastroenterologist Should Know About Antireflux Surgery (S Park et al. Clin Gastroenterol Hepatol 2020; 18: 1923-1929)
A couple excerpts:
Selecting Patients for Surgery: Current guidelines fall short in determining appropriate patients who would benefit most from surgery. For instance, the recommendation that a desire to discontinue PPI therapy is a suitable indication for antireflux surgery fails to recognize that 62% of patients end up back on PPIs within 9 years. Furthermore, indicating that those patients who failed medical management would benefit from surgery neglects the fact that the patients who respond best to antireflux surgery are those who have responded well to PPI therapy in the first place
Complications: Late postoperative complaints are more common and often are referred back to the referring gastroenterologist for diagnosis and management. These include late-onset dysphagia (3%–24%), recurrent heartburn (up to 62%), gas-bloat syndrome (up to 85%), and diarrhea (18%–33%). Anatomic failure of the fundoplication (Figure Below) can present a unique challenge to the clinician because the symptoms and patient presentation (postoperative dysphagia, regurgitation, and heartburn) can be clinically indistinct from the issues seen commonly after this surgery even in the best of circumstances. Therefore, the gastroenterologist should assess symptoms carefully in a stepwise approach with upper endoscopy, barium swallow, esophageal manometry, and/or ambulatory pH monitoring when appropriate and plan any interventions based on objective findings from focused testing.
- Antireflux Surgery Has No Significant Impact on the Progression of Barrett’s Esophagus to Esophageal Adenocarcinoma: Endoscopic Ablation of Dysplastic Barrett’s Esophagus Still Is Recommended
- Medical Therapy Is More Cost Effective Than Surgical Treatment if the Cost of the Drug Is Low
- Several New, Less-Invasive Surgical and Endoscopic Antireflux Procedures Are Now Food and Drug Administration Approved, Available, and Appear Promising
Related blog posts:
JV Ludvigsson et al. Annals of Internal Medicine 2020; https://doi.org/10.7326/M20-0167. Full Text: Maternal Influenza A(H1N1) Immunization During Pregnancy and Risk for Autism Spectrum Disorder in Offspring
- In total, 39 726 infants were prenatally exposed to H1N1 vaccine (13 845 during the first trimester) and 29 293 infants were unexposed.
- Mean follow-up was 6.7 years .
- 394 (1.0%) vaccine-exposed and 330 (1.1%) unexposed children had a diagnosis of ASD.
My take (borrowed from authors): This large cohort study found no association between maternal H1N1 vaccination during pregnancy and risk for ASD in the offspring.
A Khan et al. Clin Gastroenterol Hepatol 2020; 18: 1913-1922. Nonceliac Gluten and Wheat Sensitivity
This useful review notes that ” there is a great deal of skepticism within the scientific community questioning the existence of NCGS as a distinct clinical disorder.”
Key points:
- The pathogenesis of NCGS is unclear and there is no known biomarker or diagnostic histologic lesion for this condition.
- In these suspected patients, it is important to first exclude celiac disease and wheat allergy (especially if a rash with eating). If celiac disease is identified, this allows for appropriate longitudinal followup, strict dietary instructions, and potential screening of at-risk family members.
- Recent studies have shown that GI symptoms in those labelled with NCGS are frequently due to dietary FODMAPs.
- In a large meta-analysis study with 1312 adults, only 16% of participants experience gluten-specific symptoms using a double-blind placebo-controlled rechallenge. In addition, 40% of participants experienced a nocebo response (ie. a greater negative effect than usual due to negative expectation from a dietary treatment)
- In clinical practice, a single blind placebo-controlled rechallenge trial has been recommended for diagnosis
My take: GFD is often unnecessary and ineffective, even in those who have previously identified gluten as a potential food trigger. Fructans are more likely to induce gastrointestinal symptoms.
Related blog posts:
Misty morning -Chattahoochee River, Island Ford
D Atkins. Annals of Internal Medicine 2020; https://doi.org/10.7326/M20-6349. Put Your Own Oxygen Mask On First
Important commentary -here’s an excerpt:
My hope that his colleagues would honor his memory by spending time taking care of themselves. “Selflessness has its price. Skip was so ready to give someone the shirt off his back that he may not have realized when he was also cold. I hope each of you—especially those of you who are doctors and nurses and caregivers—will take time to be selfish when you need to be. Make a lunch date with your Skip to complain about your problems. Put your own oxygen mask on first.”
gutsandgrowth 