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.
A recent NT Times article: Can Grapefruit Juice Affect My Thyroid Medicine?
Link: list of medications affected by grapefruit/grapefruit juice
An excerpt:
“You don’t have to drink liters and liters of the stuff to have an effect,” Dr. Bailey said. For example, he said, “if you take simvastatin and drink a single glass of grapefruit juice, it’s like taking three times the dose,” though the impact can be much more or much less, since individual susceptibilities vary widely….Other citrus fruits like Seville oranges, limes and pomelos can also produce a similar effect.
A recent NPR story (A Gulp Of Genetically Modified Bacteria Might Someday Treat A Range Of Illnesses) explored new research regarding ingestion of genetically modified gut bacteria for medical purposes.
Two of the examples that were highlighted included phenylketonuria (PKU) and cirrhosis. For each disorder, the researchers are modifying E coli. For PKU, this may allow individuals to consume foods like milk and meat that usually would make them sick because individuals with PKU develop toxicity in response to phenylalanine in their diet. For cirrhosis, the genetically modified E coli help eliminate the elevation of ammonia which is due in part to gut bacteria and in part due to liver dysfunction. The report notes that the application of this science is likely to impact many other disorders including ulcerative colitis.
These efforts represent an exponential change to modifying the gut microbiome to enhance health.
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In high school, the usual advice on multiple choice questions was to avoid picking “always” and “never” on multiple choice questions.
A recent commentary (KH de Boer et al.”Thiopurine Therapy in Inflammatory Bowel Diseases: Making New Friends Should Not Mean Losing Old Ones”Gastroenterol 2019; 156: 11-4) makes the point that “never” is probably the wrong answer with regard to thiopurine usage.
Key points:
- “Thiopurine therapy has proven its value in maintenance of remission, decreased need for surgery, lowered colorectal cancer risk, less phenotypic disease progression, and synergistic effects when used with infliximab therapy, including increased biologic drug levels and less antibody formation.”
- “Notwithstanding the extensive experience by many physicians, the clinical use of conventional immunosuppressive therapies has been questioned in recent years.”
- “In this issue of Gastroenterology, Hanauer et al share their expert opinion on the evolving use of thiopurines and methotrexate in daily practice. In their literature review, the importance of assessing the risks (infections and cancer risk) and benefits (maintenance of remission) of thiopurine therapy is highlighted”
- Lymphoma risk: “The recent nationwide cohort study based on French National Health Insurance databases is illustrative. Including 189,289 patients, it was demonstrated that both thiopurine (adjusted hazard ratio of 2.6) and anti-TNF monotherapy (adjusted hazard ratio of 2.4) were associated with a similar small but statistically significant increased risk of lymphoma. Furthermore, combination therapy of thiopurine and anti-TNF was associated with a higher chance of developing a lymphoma (adjusted hazard ratio of 6.1).”
- “The individual absolute risk remains low, especially in patients without additional risk factors such as a young age in male patients and negative Epstein-Barr virus serology.”
The author’s conclusion: “The thiopurines are not perfect regarding both efficacy and toxicity, but in recent years they may have been portrayed in a worse light than they deserved. No doubt, the thiopurines will be surpassed eventually by newer safe and economical (oral) therapies, but it is too early to discard these old friends.”
Related blog posts:
Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician. 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.
Monticello
A recent study (O Olen et al. Gastroenterol 2019; 156: 614-22) was summarized quite succinctly by NEJM journal watch:
Using the Swedish National Patient Registry data, investigators identified 9442 incident cases of IBD diagnosed in patients under age 18 years from 1964 through 2014. Based on 139,000 person-years of follow-up, results were as follows:
- There were 259 deaths among people with IBD (133 were from cancer and 54 from digestive disease).
- The all-cause mortality rate in these patients was 2.1/1000 person-years, compared with 0.7 in matched reference individuals from the general population.
- The average age at death was 61.7 compared with 63.9 years in the reference group.
- The hazard ratio for death was 3.2 and was higher in those with ulcerative colitis (HR, 4.0), especially if they had concomitant primary sclerosing cholangitis (HR, 12.2), a first-degree relative with ulcerative colitis (HR, 8.3), or a history of surgery (HR, 4.6).
- Mortality risks were similar when limited to the period after the introduction of biologics (2002–2014).
My take: This study found that having IBD diagnosed in childhood increased the risk of mortality (~1 extra death for every 700 patients followed for 1 year) especially in patients with concomitant PSC and in patients with severe ulcerative colitis. The study did not see an effect of the newest therapies but was underpowered to directly assess this effect.
Related blog post:
Chattahoochee River, near Azalea Drive
A recent retrospective study (T Greuter et al. Clin Gastroenterol Hepatol 2019; 17: 419-28) shows that patients with eosinophilic esophagitis who continued to take swallowed topical corticosteroids (STC) did much better than patients who did not.
Using the Swiss EoE database, the authors analyzed 229 patients with a mean age of 39 years at diagnosis. Median followup was 5 years. The authors initiated STC, almost all received fluticasone, at 1 mg BID for 2-4 weeks followed by maintenance treatment indefinitely.
Key findings:
- There was frequent discontinuation of STC by patients, such that patients were actually taking STC at only 41% of visits.
- Higher proportions of patients taking STCs were doing well compared to those not taking STCs:
- clinical remission was 31% compared to 4.5% respectively (P<.001),
- endoscopic remission was 49% compared to 18% respectively (P<.001)
- histologic remission was 45% vs 10% respectively (P<.001)
- complete remission was 16% vs 1% respectively (P<.001)
- No dysplasia or mucosal atrophy was detected. Esophageal candidiasis was observed in 2.7% of visits in patients taking STC
My take: This study shows that patients who maintained STC therapy had better esophageal outcomes than patients who stopped their treatment. What is not known is the optimal long-term dose.
Related blog posts:
Pictures from “Old Rag” Hike, Shenandoah National Park
A recent study (I Hirano et al. Gastroenterol 2019; 156: 592-603) showed that RPC4046, a monoclonal antibody against IL13 is a promising agent for eosinophilic esophagitis. This multicenter double-blind study with 99 adults compared RPC4046 at doses of either 180 mg or 360 mg to placebo for 16 weeks. Endoscopy was performed at baseline and at 16 weeks. The study population included a high number who were considered steroid-refractory and excluded patients who were responsive to proton pump inhibitors. The study drug was administered initially as an IV load followed by weekly subcutaneous injections.
Key findings:
- Mean changes in esophageal eosinophil count dropped by 94.8 in patients receiving 180 mg dosing and 99.9 in patients receiving 360 mg dosing. In contrast, placebo-treated patients had a meager reduction of 4.4.
- In this phase II study, there were no serious safety issues identified
- There were no significant changes relative to placebo in dysphagia symptoms using the DSD (dysphagia symptom diary) composite score. Though there was improvement in global PRO measures compared to placebo.
There is an associated editorial (pg 545) explains the need for better therapies. While both dietary therapies and topical steroids are likely effective in >70%, dietary therapy is plagued by problems with long-term adherence and there may become less effective with longer-term administration.
My take: Particularly for patients with refractory EoE, newer therapies are needed. Given the chronic nature of EoE, cost of new treatments could be another hurdle.
Related blog posts:
It is tiresome how many products are marketed with baseless claims of preventing dementia. Some pushback:
NY Times: Supplements Won’t Prevent Dementia. But These Steps Might.
An excerpt:
The Food and Drug Administration estimates that 80 percent of older adults rely on dietary supplements, many purporting to prevent or treat Alzheimer’s and other forms of dementia…
Vitamins, various antioxidants, concoctions derived from animals and plants — “we see plenty of ads on TV, but we have no evidence that any of these things are preventive,” said Dr. Steven DeKosky, a neurologist and deputy director of the McKnight Brain Institute at the University of Florida.
Dr. DeKosky led a federally supported study of Ginkgo biloba extract, for instance, following more than 3,000 people for seven years to see if it reduced dementia. It didn’t.
Some of the steps that may help according to article:
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Increased physical activity;
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Blood pressure management for people with hypertension, particularly in midlife;
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And cognitive training.
Tonight one of my colleagues, Ben Gold MD, is being honored by the Crohn’s and Colitis Foundation, Georgia Chapter, as Premier Physician of the Year. Well deserved!!!
A recent study (Vilanova-Sanchez A, et al. J Pediatr Surg 2018; 53: 722-7) provides reassurance regarding the safety of senna-based laxatives in kids.
The authors performed a literature review and reviewed their personal experience (2014 to 2017) of prescribing Senna in 640 patients. In this cohort, 230 (36%) had functional constipation.
Key findings:
- Besides abdominal cramping or diarrhea during the first weeks of administration, there were no other long-term side effects from Senna found in the pediatric literature with long-term treatment
- At their institution, 83 (13%) patients presented minor side effects such as abdominal cramping, vomiting or diarrhea, almost half (48%) of which resolved spontaneously within two weeks.
- “We did not see any side effects in 540 (84.3%) patients.” The median length of treatment was 338 days and median dose was 17.5 mg. “430 (80%) of them are currently taking Senna.”
- 17 patients (2.2%) developed blisters during their treatment. Patients who developed blisters had higher doses 60 mg/day; 60 [12–100] vs. 17.5 [1.7–150] (p < 0.001). All of the blistering episodes were related to night-time accidents, with a long period of stool to skin contact.
In their discussion, the authors note that senna and other anthranoid glycosides are not absorbed in the small intestine. They are maintained as prodrugs until they reach the large intestine where they are metabolized to the active form. In addition, “despite an extensive search of both the medical and lay literature we did not find any reference to long term tolerance due to treatment which we find is a frequently mentioned concern by families and clinicians”
The authors comments on the study from Nationwide Children’s Hospital website:
- “The safety profile of senna is as good as or better than many common medications a person would be on, including over-the-counter medications routinely given to very young children, and tolerance does not appear to be a concern,” says Dr. Levitt, who is also a professor of Surgery at The Ohio State University College of Medicine. “We hope this paper will make physicians more comfortable in using senna-based laxatives, and that they will be more widely used.”
- Senna is often more effective than polyethylene glycol. This study shows that it is safe as well. “A physician should consider senna as the first line medication,” says Dr. Levitt.
My take: Many patients who come to pediatric gastroenterologists have not responded to polyethylene glycol. Senna has been effective in many of these patients as part of a bowel regimen which usually includes behavior modification and diet.
Related blog posts:
Pictures from Joshua Tree National Park
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