Author Archives: gutsandgrowth

Unknown's avatar

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.

Liver Shorts August 2018

Posted on by

M Yakoot et al. JPGN 2018; 67: 86-89. This prospective, open-label, unblinded study from Egypt indicated that 29 of 30 (96.7%) pediatric (12-17 yr) patients with HCV (genotype 4) attained an SVR12 with sofusbuvir/daclatasvir.  No serious adverse effects were evident.  The one patient who did not achieve SVR12 was lost to followup but had viral negativity after completing treatment.

Related blog post: New HCV Treatment Effective in Adolescents –Important Study Now Published Online

O El-Sherif, ZG Jiang et al. Gastroenterol 2018; 154: 2111-21. This study showed that a “BE3A Score” based on BMI <25, no Encephalopathy, no Ascites, Albumin >3.5 and ALT >60 IU/L could be used to discriminate the likelihood of reducing the Child-Pugh-Turcotte (CPT) score to class A in patients with hepatitis C virus-associated decompensated cirrhosis who received DAA therapy.  This retrospective  analysis was based on 4 trials of a sofusbuvir-therapy with 502 CPT class B and 120 CPT class C patients.

AH Ali et al. Hepatology 2018; 67: 2338-51.  This study convincingly shows that surveillance for hepatobiliary cancers improves outcomes in patients with primary sclerosing cholangitis.  Among their cohort of 830 patients (Mayo clinic), 79 developed malignancies.  Of those under surveillance (n=40), the 5-year survival was 68% compared to 20% for those who had not been under surveillance.  While the true cynic might ascribe some of the difference to ‘lead-time’ bias, this is unlikely to account for this difference at 5 years.

F Aberg et al. Hepatology 2018; 67: 2141-49.  This Finish-population prospective study, over an 11 year follow-up, using a nationally-representative cohort (n=6771) showed that even moderate alcohol consumption worsened outcomes (eg hepatic decompensation, hepatocellular carcinoma) in patients with nonalcoholic fatty liver disease.  In addition, the authors showed that diabetes the most significant predictor of poor outcome (HR 6.79). In a related commentary, pg 2072-73, the authors state that this article “put an end to the ongoing ddebate whether moderate alcohol drinking (less than 20 g of alcohol/day or 2 drinks per day) could be helpful.”

IBD Shorts August 2018

Posted on by

Vitamin D Receptor Signaling in IBD. Inflamm Bowel Dis 2018; 24: 1149-54.  This article reviews the ways vitamin D/vitamin D receptor may contribute to the genetic, environmental, immune, and microbial aspects of IBD.

LY Chi et al. Inflamm Bowel Dis 2018; 24: 1344-51. This study with 223 pediatric patients & young adults found that current or prior combination therapy with infliximab, compared to monotherapy resulted in higher infliximab levels and lower antibody formation. Combination agent was mainly methotrexate (n=71) rather than thiopurine (n=13). In those with infliximab dose <10 mg/kg, those currently receiving combination therapy had median level of 11.1 compared with 7.0 for prior combination and 5.86 for monotherapy (never combination).

CM Johnson et al. Clin Gastroenterol Hepatol 2018; 16: 900-7.  In this retrospective study with 1466 patients with Crohn’s disease, the subset of patients with granulomas (n=187, 12.8%) were associated with a more aggressive phenotype and a younger age at diagnosis (23.6 years compared with 27.9 years; P= .0005). These patients had higher rates of steroid use, narcotic use, more stricturing and penetrating disease along with increase rates of surgery.

 

Declining Role of Fundoplication in Esophageal Atresia, Too

Posted on by

A recent study (SA Pellegrino et al. J Pediatr 2018; 198: 60-6) examines the likelihood of redo fundoplication for esophageal atresia (EA) in comparison to redo fundoplication for other indications.

Key findings:

  • Among all EA cases, n=344 (1994-2013), 85 underwent fundoplication (single-center study from Melbourne)
  • Rates of fundoplication were declining over study period: there was a 37% drop from 2010-2013 compared to 1994-97.
  • Overall, 767 patients had a fundoplication (n=682 without EA).  The rates of redo fundoplication were similar 11/85 compared with 53/682, despite the fact that EA patients had earlier surgery with median ages of 7.2 months versus 23 months, respectively.

Factors leading to fewer fundoplications:

  • Improving medical therapies, including proton pump inhibitors and use of jejunal feedings
  • Awareness that fundoplication may not be curative and is associated with significant morbidity

Anecdotally, I have had some EA patients whose lives were transformed positively by fundoplication, though many are difficult operations due to anatomic factors like small gastric volumes and pulmonary issues.  Careful selection and surgical expertise are essential to good outcomes.

My take: The authors note that “this study challenges the assertion that fundoplicaiton is less successful in patients with EA.”

Related blog posts:

Gibbs Gardens

Costs/Yield of Diagnosing Cyclic Vomiting Syndrome

Posted on by

A recent retrospective study (CJ Lucia-Casadonte et al. JPGN 2018; 67: 13-17) examined the costs and yield of testing for Cyclic Vomiting Sydrome (CVS).

As a bonus –this is a study with CME available (& ABP MOC): NASPGHAN-JPGN CME The full text can be obtained at CME website.

This study looked at 503 charts from a single center using ICD-9 coding to identify patients. In this group, 165 (33%) had a diagnosis of CVS with 135 of this group (82%) meeting NASPGHAN diagnostic criteria with a mean age of 7.7 years.

Key findings:

  • 6 (4%) had a change in management based on CVS evaluation
  • The mean cost for screening was $6125.02 per patient
  • Atypical symptoms included bilious emesis in 9 (7%), abdominal pain in 67 (50%), attacks precipitated by fasting 1 (0.7%), and neurologic abnormalities in 3 (2%).
  • Brain MRI was performed in 68 patients and 10 were considered abnormal; though, only 1 (0.7%) had a change in management related to increased intracranial pressure (this patient had hx/o hydrocephalus). Other findings included Chiari I malformation, cerebral cyst, macrocephaly, and abnormal myelination pattern.
  • Other underlying diagnosis: UPJ obstruction (n=1), unspecified metabolic condition with carnitine deficiency (n=1), and eosinophilic esophagitis.
  • Given the costs involved, the authors reiterate NASPGHAN recommendations to avoid a ‘shotgun’ approach and note that it has previously been shown that “the most cost effective therapy in the management of CVS to be UGI with small bowel follow through (SBFT) with empiric treatment.”  Additional evaluation would be indicated for those with red flags and/or progressive or a changing pattern of vomiting episodes.
  • The authors indicate that endoscopy was the most costly evaluation tool at their institution ($11,500) and only used in 36 patients and was considered to have a low yield.

My take: This study underscores the low yield and expense involved in the evaluation of pediatric CVS; yet, it remains difficult to balance this with the concern of overlooking some anatomic and metabolic problems which can benefit from a timely diagnosis.

Related blog post:

Gibbs Gardens 2018

 

Common Sense Media Web Site

Posted on by

“Common sense is not so common.” Voltaire,, Dictionnaire Philosophique 1764

A website that I learned about recently from the Journal of Pediatrics article, “The Elephant in the Examination Room: Addressing Parent and Child Mobile Device Use as a Teachable Moment:”  commonsensemedia.org

“Common Sense is the nation’s leading nonprofit organization dedicated to improving the lives of kids and families by providing the trustworthy information, education, and independent voice they need to thrive in the 21st century.”
This website has extensive resources for families regarding all forms of media.  This includes advice on apps, age for using smartphones, encouragement for device-free dinners, movie/TV reviews and more.
The AAP also has a media use plan tool: www.healthychildren.org/mediauseplan based on children’s ages.

Dietary Patterns in First Year of Life May Increase Risk of Celiac Autoimmunity

Posted on by

M Barroso et al. Gastroenterol 2018; 154: 2087-96.

Background: “Western-like diets –mainly characterized by high intake of red and processed meats, refined grains, simple sugars, and saturated fats and low intake of fruits, vegetables, and whole grains– have been associated with low-grade chronic inflammation, which is involved in the etiology of inflammatory conditions.” Ref: Br J Nutr 2015; 114: 999-1012.

To examine how diet may influence the development of celiac autoimmunity, defined by TG2A positivity, the authors examined a subset of patients (n=1997) from the prospective Generation R study (Netherlands); 27 in this cohort developed celiac autoimmunity (1.4%).

Key finding:

  • Higher adherence to a “prudent” diet which had a higher intake of vegetables, vegetable oils, pasta, and grains and low consumption of refined cereals and sweet beverages at 1 year of age was associated with a lower odds of celiac autoimmunity at 6 years of age with an odds ratio of 0.67.

This study is limited by the relatively low number who had celiac autoimmunity and by its use of a food questionnaire.

My take: This study indicates that diet plays a role in the development of celiac along with other disease, but this likely involves a complex mix of components rather than a single toxic agent.

Related blog posts:

How Many Eosinophils Indicate Eosinophilic Gastroenteritis or Colitis?

Posted on by

A recent study (Z Kiss et al. JPGN 2018; 67: 6-12) provides more data on normative values for eosinophil counts in the GI tract.  For their report, the authors reviewed 3 databases for a systematic search of the literature. They screened 1316 abstracts but found only 8 articles with complete/relevant data.  Among these 8 articles, data regarding each segment of the GI tract was present in as few as 3 articles and as many as 6 articles. The authors provide confidence intervals (CIs) and prediction intervals (PIs); the latter account for the wider uncertainty due to insufficient data.

Key points:

Normal eosinophil cell number per high-power field (HPF area = 0.2 mm squared):

  • Duodenum 8.26 with CI 4.71-11.8 and PI of 0 to 20.57
  • Terminal ileum 11.52 with CI 7.21-15.83 and PI of 0 to 60.64
  • Cecum 14.12 with CI 9.05-19.19 and PI of 0 to 38.64
  • Ascending colon 13.25 with CI 8.65-17.86 and PI of 0 to 35.42
  • Transverse colon 11.52 with CI 7.80-15.23 and PI of 0 to 25.85
  • Descending colon 10.32 with CI 7.22-13.42 and PI of 0 to 49.10
  • Sigmoid colon 8.80 with CI 6.82-10.77 and PI of 0 to 32.49
  • Rectum 7.39 with CI 4.20-10.59 and PI of 0 to 22.33

Other points:

  • The authors note that eos/HPFis a flawed measurement due to technical parameters of the microscope.  Some HPFs are bigger than others –this could affect eosinophil count up to 5-fold.  The authors specify an HPF to be =0.2 mm squared.
  • Obtaining appropriate mucosal samples for normal number of eosinophil counts can be difficult.  Even patients with functional disorders like irritable bowel syndrome and nonulcer dyspepsia could have abnormal numbers of eosinophils.

My take: These numbers of expected eosinophil counts for pediatric histology are a good starting point.  The prediction intervals remain large due to insufficient data.

Related blog posts:

Gibbs Gardens

Pediatric NAFLD: You Don’t Have to be Obese/Overweight to Have Fatty Liver Disease (but it helps)

Posted on by

A recent study (P Kumar et al. JPGN 2018; 67: 75-9) examined suspected NAFLD in 12 to 18 year olds using data from NHANES. In the analysed cohort, there were 124 suspected NAFLD and 1385 without suspicion of NAFLD.  This subset was weight to represent a U.S. population of over 18 million.

Key definitions:

  • Suspected NAFLD was defined by abnormal ALT (>25.8 U/L for boys and >22.1 U/L for girls) who did not have another explanation (eg. viral hepatitis, medication)
  • Lean BMI was defined by BMI less than 85th% for age
  • Hypertriglyceridemia ≥ 150
  • Low HDL ≤ 40 mg/dL
  • HOMA-IR =fasting glucose x insulin (microU/mL) divided by 405. Insulin resistance was defined as HOMA-IR ≥ 3

Key findings:

  • Suspected NAFLD affects ~8% of lean adolescents in the U.S.
  • Hypertriglyceridemia was noted in 10 of 124 suspected NAFLD and was a risk factor (P=0.028) as was Low HDL which occurred in 15 (P=0.016) and IR which occurred in 43 (P=0.053)

My take: Elevated ALT, a marker for fatty liver disease, is common even in adolescents without obesity. Elevated triglycerides, low HDL, and insulin resistance are all risk factors for suspected NAFLD in non-overweight/non-obese teens.

Related blog posts:

Cumberland Island 2018

MRE Does Not Fare Well at Detecting Lesions Evident on Upper Endoscopy

Posted on by

A recent study (PC Church et al. JPGN 2018; 67: 53-8) examined how well EGD findings were detected by MRE in 188 children (mean age 14 years).

Key findings:

  • EGD was macroscopically abnormal in 93 (49%) with ulcerations being the most common abnormality in 66 (35%).
  • In contrast, the local radiologist identified UGI inflammation in 7 (4%) and the central radiologists identied UGI inflammation in 20 (22%).  “There was no agreement between local and central radiologists when examining the UGI as a whole (κ=-0.02, P-0.59)”
  • The local radiologists “correctly identified only 5 of 93 (8%) patients with UGI findings on EGD.”  The central radiologists “correctly identified 9 of 45 (30%) patients with UGI findings on EGD.”

The authors state that “the Porto criteria mandate the performance of EGD for all pediatric patients suspected of having IBD. Our study has demonstrated that MRE cannot be relied upon as the sole method of evaluating the UGI.”

My take: For those who take care of children with IBD, this study will not come as a surprise as many of the UGI findings (found at endoscopy) are subtle.  This study does quantify the much higher sensitivity of endoscopic evaluation and is similar to studies that have compared capsule endoscopy to MRE.

Related blog posts:

 

Cumberland Island 2018