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.

Elastography –Accuracy in Children

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Background: Transient elastography may help identify patients at greater risk for advanced fibrosis but there is a significant overlap between fibrosis stages and values with transient elastography. In some conditions, like fatty liver, elastography may be less helpful than in others (eg. chronic viral hepatitis).

A recent study (J Pediatr 2018; 198: 84-9) examined the results of transient elastography in 267 children (97 for calibration, 170 for validation) between 2006-2016.  The median age was 13 years.  Liver diseases included autoimmune (21%), viral (19%), fatty liver (11%), cholestatic (9%), primary sclerosing cholangitis (9%) and post-transplantation (12%).

Key findings:

  • Cut points to discriminate F3-F4 and F4 were >8.6 kPa and >11.5 with 81% and 84% accuracy, respectively in calibration cohort
  • To discriminate F3-F4 and F4 in validation cohort, these cut points, >8.6 kPa and >11.5, had accuracy of 67% and 75% respectively

Figure 2 provides much greater detail in the typical values for each Metavir stage. For example, in the calibration cohort, the median values and range were the following:

  • F0   6.0 (3.2-12.4)
  • F1   6.2 (3.2-75)
  • F2   5.8 (2.5-52.7)
  • F3  10.3 (4.9-32.6)
  • F4  20.5 (5.9-68.1)

In the validation cohort, values were similar:

  • F0   6.2 (3.0-75.0)
  • F1   7.1 (3.3-31.6)
  • F2   7.1 (2.5-52.7)
  • F3  9.6 (4.4-75.0)
  • F4  20.8 (6.8-75.0)

My take: Elastography in measuring liver stiffness is a lot like checking a CRP for inflammatory bowel disease.  That is, it can be helpful but cannot be relied on the same way as many radiographic tests (eg. CT scans for appendicitis).

Related blog post:

Moraine Lake, Banff

Expert Advice on Bloating

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A recent article (AK Kamboj, AS Oxentenko. Clin Gastroenterol Hepatol 2018; 16; 1030-33) provides some useful guidance on bloating.

They describe bloating as an acronym:

  • Bowel disturbance (constipation, SIBO, celiac, IBD)
  • Liquid (ascites)
  • Obstruction
  • Adiposity
  • Thoracic (overexpansion, diaphragm contraction)
  • Increased sensitivity (functional bloating, IBS, dyspepsia)
  • Neuromuscular (gastroparesis, impaired accommodation, medications)
  • Gas (aerophagia, dietary sources, post-Nissen)

The diagnostic approach they recommend:

  • If bloating with diarrhea, evaluate diet, SIBO, celiac, IBD, IBS-D, and medications
  • If bloating with constipation, evaluate for constipation, pelvic floor dysfunction, IBS-C, and medications
  • If bloating and suspected mechanical disturbance, evaluate for gastric outlet obstruction/small bowel obstruction
  • If bloating without bowel disturbance, consider aerophagia, gastroparesis, and functional dyspepsia

Treatment:

  • Treat any underlying disorder
  • For mild symptoms, reassurance may be sufficient
  • Dietary modifications to avoid food triggers & reduce fermentable food products
  • Treating constipation when present
  • A large number of other treatments can be considered as well including antispasmotics, agents to help with visceral hyperalgesia, cognitive behavioral therapy

My take: I like BLOATING acronym, though the 5 Fs I learned a long time ago is a little easier for me to remember — which include flatus (gas), feces (constipation), fluid, fat, and fetus/masses. Flatus can be caused by swallowing air (aerophagia), malabsorption (celiac, lactose intolerance, parasites), muscular discoordination (abdominal phrenic dyssynergia), and motility problems.”

Related blog posts:

Sunshine Meadows, Banff National Park

Active Colitis More Likely in Children in Clinical Remission Who Have PSC and IBD

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A recent study (A Ricciuto et al. Clin Gastroenterol Hepatol 2018; 16: 1098-1105) provides more data regarding the lack of symptom correlation and inflammatory bowel disease (IBD) activity in children with primary sclerosing cholangitis (PSC).

In a prospective study of children with colonic IBD with and without PSC, the authors followed clinical features (eg. PUCAI), fecal calprotectin and endoscopy severity.

Key findings:

  • Patients with PSC-IBD (n=37) in clinical remission had higher endoscopic scores and greater odd of active endoscopic disease than IBD-only controls (n=50) (odds ratio 5.9, with CI 1.6-21.5)
  • Fecal calprotectin level <93 mcg/g were identified mucosal healing with 100% sensitivity and 92% specificity when compared with UC Endoscopic Index of Severity (UCEIS)

Overall, this study is in agreement with a prior adult study showing higher levels of active disease in those with PSC-IBD compared to those with IBD alone, despite clinical remission (Why does PSC increase the risk of colorectal cancer in UC?).

My take: Particularly in individuals with the combination of IBD-PSC, objective biomarkers (eg. Calprotectin) are needed to identify the accuracy of clinical remission; though, even in patients with IBD without PSC, objective biomarkers are needed as well due to the limitations of clinical symptom indices.

Related blog posts:

Moraine Lake, Banff

Clinical Practice Update: Extraesophageal Symptoms Attribute to Gastroesophageal Reflux Disease

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A recent practice update (MF Vaezi, D Katzka, F Zerbib. Clin Gastroenterol Hepatol 2018; 16: 1018-29) reviews the data and provides up-to-date recommendations for extraesophageal symptoms attributed to gastroesophageal reflux disease (GERD) in adults.

Extraesophageal symptoms attributed to GERD could include cough, asthma, hoarseness, sore throat, sinusitis, dental erosions, and ear pain.

Key recommendations:

  • Non-GI evaluations by ENT, pulmonary and/or allergy are essential and often should be performed initially in most patients.
  • “Abnormalities seen on endoscopy have poor predictive value for determination of GERD as the cause of extraesophageal symptoms”
  • “Ambulatory pH/impedance monitoring…have limited ability to establish GERD as the cause of an extraesophageal symptom.  The main role of testing is to document the absence of GERD.”
  • Empiric therapy with ‘aggressive’ acid suppression for 6-8 weeks can help in assessing association between reflux and extraesophageal symptoms.
  • Testing for reflux on therapy should be considered mainly in those with high probability of baseline reflux (eg. previous esophagitis, Barrett’s esophagus, or prior abnormal pH study).
  • Surgical treatment is discouraged in those with extraesophageal reflux symptoms unresponsive to aggressive PPI therapy

Related blog posts:

Flower in Canadian Rockies: Western Anemone

Management of Pediatric Ulcerative Colitis -ESGHAN/ECCO Recommendations

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Two complementary articles provide extensive guidance on the management of ulcerative colitis and acute severe colitis:

  • D Turner et al. JPGN 2018; 67: 257-91
  • D Turner et al. JPGN 2018; 67: 292-310

Between the two articles there are more than 60 practice recommendations, more than 120 practice points, and more than 700 references.  As such, these articles are probably better for a journal review meeting rather than a brief blog post.

Figure 1 (2nd article, page 299) provides a handy algorithm for management of acute severe colitis:

  • On day 1-2, the algorithm recommends stool studies, starting methylprednisolone, and withholding 5-ASA.
  • On day 3, if PUCAI <45, suggests continuing steroid and transitioning to oral therapy when PUCAI <35.  On day 3, if PUCAI ≥45, the authors suggest screening for second line therapy, involve surgery (to discuss colectomy if there is nonresponse to medical treatment), and looking for CMV infection (eg. sigmoidoscopy).
  • On day 5, if PUCAI >65, recommendation is to start 2nd line Rx (eg. infliximab, tacrolimus, or cyclosporine). If PUCAI 35-65, continue corticosteroids for additional 2-5 days. The authors note that infliximab is preferred 2nd line Rx unless planning to transition to vedolizumab.
  • The authors recommend weaning corticosteroids when 2nd line Rx is started
  • The authors recommend addition of an immunomodulator for at least 6 months in responders to infliximab in effort to lower the risk of colectomy.
  • The authors state “urgent colectomy is recommended following failure of 1 second-line therapy.”

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

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Sitting Better (like a dog) to Fix Back Problems

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On the way to work, I heard this NPR story:  To Fix That Pain In Your Back, You Might Have To Change The Way You Sit

An excerpt:

“Most of us do not sit well, and we’ve certainly been putting a lot more stress on our spines,” says Khan, who operates on spines at Sutters Health’s Palo Alto Medical Foundation.

If we change the way we sit, Khan says, it will help to decrease back problems.

“We should sit less, and we should sit better,” he says.

Over the past century or so, many Americans have lost the art of sitting, he says. Most people in the U.S. — even children — are sitting in one particular way that’s stressing their backs. You might not realize you’re doing it. But it’s super easy to see in other people.

Here’s how: Take a look at people who are sitting down – not face-on but rather from the side, in profile, so you can see the shape of their spine.

There’s a high probability their back is curving like the letter C — or some version of C. Or it might make you think of a cashew nut, sitting in the chair. There are two telltale signs: Their shoulders curve over and their butts curve under. That posture is hurting their backs, Khan says…

To figure out how to shift your pelvis into a healthier position, Sherer says to imagine for a minute you have a tail. If we were designed like dogs, the tail would be right at the base of your spine…

To straighten out the C shape, Sherer says, “we need to position the pelvis in a way that this tail could wag.”

My take -disclosure: I am not a back expert –so I am not sure about the expertise of some of this advice.  Also, this article is in sync with a previous NPR segment —Back Pain May Be the Result of Bending Over at the Waist (Lost Art of Bending Over: How Other Cultures Spare Their Spines)

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

Marijuana Use in Adolescents/Young Adults with Inflammatory Bowel Disease

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A recent study (EJ Hoffenberg et al. J Pediatr 2018; 199: 99-105) examined the use of marijuana in 13-23 year age group with inflammatory bowel disease (IBD) at the Children’s Hospital for Colorado.

This relatively small study (n=99 — 62 with Crohn’s, 27 with ulcerative colitis, 10 with indeterminate colitis) found the following:

  • Marijuana use was endorsed by 32 (32%) and that 9 used daily or almost-daily.
  • Users were 10.7 times more likely to perceive low risk of harm (P<.001)
  • 17 of 30 stated a medical reason for use (16 with physical pain)
  • The most common route of use was smoking (83%)

Limitations:

  • 80% of participants had inactive or mild disease
  • There was no control (non-IBD) group to compare frequency of marijuana use
  • Study performed in state with legalized recreational marijuana

My take: We know very little about how marijuana impacts IBD course and whether it is safe.  This study indicates frequent use of marijuana in the 13-23 year age group.  Thus, it is an issue that needs to be examined further.

Related blog posts:

Three Sisters, Peaks near Canmore, Alberta

Parasitology in 2018: Should we still be ordering O&P times three?

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A terrific review article (S Mohapatra et al. Am J Gastroenterol 2018; 113: 805-18) provides a great deal of information about gastrointestinal parasites. Thanks to Ben Gold for this reference (& don’t forget to vote for NASPGHAN president).

Generally, the authors dispute the usefulness of testing for ova and parasites (O&P) with three separate specimens.  While classic training has noted the intermittent shedding of parasites and the suboptimal sensitivity of O&P, the authors note that a recent study showed a detection of 91% of parasites in the first stool sample.  In addition, newer PCR based assays are more appropriate in many clinical situations due to their improved sensitivity.

The authors first review the protozoa, which are single-celled, motile, free-living organisms, in depth & summarized in Table 1; these include the following:

  • Amoeba: Entamoeba histolytica (E histolytica),
  • Dientamoeba fragilis
  • Blastocystis hominis
  • Coccidia: Cryptosporidium, Cystiospora, Cyclospora
  • Ciliates: Balantidium coli
  • Flagellates: Giardia lamblia
  • Microsporidiosis
  • Trypanosoma cruzi

Next, they review the helminths in depth and in Table 2, which are large, multicellular organisms that can be seen with the naked eye and include the following:

  • Ascariasis: A lumbridcoides
  • Capillariasis
  • Diphyllobothriasis
  • Enterobiasis: E vermicularis
  • Hookworm disease: A dudenale, N amercanus
  • Hymenolepiasis
  • Strongyloides: S stercoralis
  • Schistosomiasis
  • Taeniasis
  • Trichinellosis
  • Trichuriasis
  • Groups of helminths: trematodes (eg. Schistosomes), cestodes (tapeworms eg. Taenia), and nematodes (roundworms eg. Ascariasis, hookworm, pinworms, and whipworms).

Key points:

  • For E histolytica, ELISA fecal antigen test is superior to O&P as is the PCR assay.  If the diagnosis of E histolytica is being considered in the setting of ulcerative colitis, the authors note that this infection must be excluded before the initiation of corticosteroid therapy since steroids can lead to hyperinfection and could be fatal.  Also, the so-called “flask shaped” ulcers seen with this infection refers to the microscopic appearance of the ulcer into the submucosa. Most infections (>90%) remain asymptomatic.
  • Blastocystis “is the most common parasite identified in stool samples in the US” though the pathogenicity remains controversial and is often self-limited.
  • D fragilis “as a pathogen is controversial…[but] recent studies on patients infected only with D fragilis have found an association with diarrhea, abdominal pain, nausea, weight loss, anorexia, and flatus which resolve after eradication.”
  • Giardiasis is “the most common intestinal parasitic disease affecting humans in the US.” PCR/molecular methods are highly sensitive (>90%) and specific (nearly 100%)
  • Enterobius vermicularis (pinworms). The “CDC does not recommend stool examination for O&P since the yield is low.” The diagnostic test is the “Scotch test” in which tape is left overnight in the perianal region and then examined for captured eggs.

Author Recommendations:

  • “Restrict stool examination [for parasites] to patients with persistent diarrheal illness with a duration greater than 7 days.”  Do not check O&P in hospitalized patients more than 3 days into their hospitalization.
  • The most  common parasitic infections, Giardia and Cryptosporidium, are best diagnosed with a stool immunoassay (EIA) rather than O&P.  For E histolytica EIA is recommended over O&P.
  • In those who are persistently symptomatic and with travel history with likely parasite exposure, stool O&P with wet mount/AFB stain/special stains for detection of rare parasites still is worthwhile.  In those without exposure history and with persistent diarrhea (after exclusion of Giardia and Cryptosporidium), consider non-infectious causes of diarrhea.
  • We discourage repeating the O&P due to the “very low incremental yield of second and third samples”

My take: This article makes a strong argument that “O&P times three” represents an outdated approach in the diagnosis of parasitic diseases in the US.

Related blog posts:

Near the top of Old Rag Mountain, Shenandoah Natl Park

 

 

 

Exercise and Income/Race/Gender in U.S.

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Thanks again to Ben Gold for another good read: S Armstrong et al. JAMA Pediatr 2018; 172(8): 732-40.

This study provides a great deal of information on the physical activity of adolescents and young adults (age group 12-29) from 2007-2016 using NHANES data from 9472 participants.  The relationship of physical activity compared with income, race and gender is explored.

Background:

  • The current recommendation is for adolescents to engage in a minimum of 60 minutes of moderate to vigorous activity per day.  At age 20, adult guidelines recommend 150 minutes of moderate activity, 75 minutes of vigorous activity  or an equivalent combination of moderate and vigorous activity per week.
  • In previous studies, one-third of adults do not meet the recommended amount of physical activity

Key findings:

  • Percentage of individuals reporting any moderate or vigorous activity: 87.9% for age 12-17 y, 72.6% for age 18-24 y, and 70.7% for age 25-29 y.
  • Mean time for moderate or vigorous activity: For males: 71.1 min or age 12-17 y, 64.3 min for age 18-24 y, and 50.3 min for age 25-29 y. For females: 56.0 min or age 12-17 y, 44.9 min for age 18-24 y, and 39.2 min for age 25-29 y.
  • Younger age, white race, and higher income were associated with greater physical activity.  The breakdown on the specifics are listed in the five Tables.

The limitations of this study include that the data are cross-sectional and do not prove causality.  In addition, the data are self-reported and some groups may over- or under-report activity.

My take: This study shows that a lot of young individuals are not physically-active whihc increases the risk of some chronic diseases.  Examining the groups that have higher and lower physical activity may help understand ways towards improvement.

During a recent trip to Charlottesville, I came across this article. Someone is identifying dog poops with Nicholas Cage’s face –to highlight the problem?  Funny stuff.

Food Additives and Child Health

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For the next several days, this blog is going to highlight articles that Ben Gold (one of my partners at GI Care for Kids) has recently sent me.  For what it is worth, I am not sure that Ben Gold actually sleeps.  He seems tireless.  He shares articles with lots of individuals in our group on a wide range of subjects.  In addition to his loaded clinic schedule, he is busy giving lectures, engaged in NASPGHAN committees, provides guidance for our research projects, participates in hospital meetings, and is active with family pursuits (super-proud Dad).

Ben is also in the running to be the next NASPGHAN president & I think he is very well-suited for this role.  He has  been a Division Chief with a distinguished career both at the CDC and Emory, and has been in a busy private practice. Between these roles, he has acquired practical knowledge with regard to negotiating with hospitals, universities, insurers and industry. This combined academic-private practice experience would benefit NASPGHAN and its members, particularly at a time when the roles of physicians and hospitals are changing so rapidly.

A recent AAP policy statement and technical report (Trasande L, Shaffer RM, Sathyanarayana; Pediatrics 2018; 142 (2): e20181408 & technical report: Pediatrics 2018; 142 (2): e20181410) highlights child health concerns and food additives.

Food additives include the following:

  • Direct additives: colorings, flavorings, and chemicals added during processing. This policy statement notes that there are 10,000 direct food additives which are allowed in the U.S.
  • Indirect additives: food contact materials including adhesives, plastics, paper which can contaminate food as part of packaging and distribution
  • Other contaminants like pesticides are not addressed in this policy statement

Key points:

  • Regulation and oversight of many food additives is inadequate.  This is due to key problems with the Federal Food, Drug, and Cosmetic Act.  Current requirements allow for a “generally recognized as safe” (GRAS) designation. The GRAS process was intended to used in limited situations, but “has become the process by which virtually all new food additives enter the market.”
  • Yet the FDA does not have adequate authority to acquire data on chemicals and data about health effects of food additives on infants and children are limited or absent.
  • Furthermore, FDA regulation does not regularly consider issues of cumulative dosing and synergistic effects of food additives.

Specific examples:

  • Bisphenols, which are used in the lining of metal cans, could result in disruption of  endocrine pathways
  • Phthalates, which are used in adhesives, lubricants, and plasticizers during the manufacturing process, can also  in disruption of  endocrine pathways
  • Perfluoroalkyl chemicals (PFCs), which are used in grease-proof paper and packaging, may result in obsesogenic activity, decreased birth weight, and disruption of endocrine pathways
  • Nitrates and nitrites, which are added as preservatives and color enhancer especially with meats, may contribute to carcinogenicity and thyroid hormone disruption
  • Artificial food colors may be associated with exacerbation of attention-deficit/hyperactivity disorder symptoms

Conflict of interest with GRAS evaluations:

  • Among GRAS evaluations, 22.4% were made by an employee of manufacturer, 13.3% were made by a consulting firm selected by manufacturer, and 64.3% were made by an expert panel selected by manufacturer or manufacturer’s consulting firm

Given the potential safety concerns of numerous additives, the policy statement makes the following recommendations for pediatricians:

  • Prioritize consumption of fresh or frozen fruits and vegetables
  • Avoid processed meats, especially during pregnancy
  • Avoid microwaving food or beverages
  • Avoid placing plastics in dishwasher
  • Recycling labeling often offers clues to the type of plastic with concern for the following codes: 3 often indicating phthalates, 6 for styrene, and 7 for bisphenols –unless labeled as “biobased” or “greenware.”

The policy statement encourages further regulatory steps for government/FDA as well.

My take: These articles sound the alarm that food additives may be making us sick.  This area is ripe for further investigations.

Bow River, Banff