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.

How Does Splenda Affect the Gut Microbiota?

Posted on June 13, 2018 by gutsandgrowth

“You should never assume. You know what happens when you assume. You make an ass out of you and me because that’s how it’s spelled.”

–Attributed to multiple individuals (but I heard this first when I watched Bad News Bears as a kid)

The increasing frequency of many conditions like inflammatory bowel disease cannot be explained by our genetics. The search for environmental triggers are ongoing. Broadly, the main suspects are dietary, antimicrobials, and pollutants. (Related blog post: Nutrition Week (Day 7) Connecting Epidemiology and Diet in Inflammatory Bowel Disease)

The latest concern is now Splenda:

“The Artificial Sweetener Splenda Promotes Gut Proteobacteria, Dysbiosis, and Myeloperoxidasse Reactivity in Crohn’s Disease-Like Ileitis” A Rodriguez-Palacios et al. Inflamm Bowel Dis 2018; 24: 1005-20. Editorial 1055-6 by B Chassaing and AT Gewirtz.

This highly technical study involved research in ileitis-prone SAMP mice and includes a huge amount of data and cool figures.

The authors note in their discussion: “The term ‘Western diets’ implies a proven shift of the microbiota that enhances the susceptibility to adherent-invasive E coli infections and intestinal inflammation in mice. In this study, we report similar findings due solely to the administration of a minor component of the diet.”

Some of the key points in the editorial:

IBD has multigenic influences and “results from a general breakdown in the normally mutually-beneficial relationship between the intestine and the complex microbial community it harbors.”
“New findings …that Splenda promotes microbiota dysbiosis in mice and exacerbates a hallmark of inflammation in ileitis-prone SAMP mice suggest that consumption of this synthetic sweetener may be a specific factor that contributes to development of IBD in persons genetically prone to this disorder.”
Splenda has two main components: sucralose (sweetener) and maltodextrin (filler)
Splenda did not “impact inflammatory markers in control mice, but rather increased such parameters in SAMP mice.”
Splenda changed the microbiota in both control mice and SAMP mice, “particularly enrichment of gamma Proteobacteria, which are broadly associated with gut inflammatory diseases.”
“Splenda may be relatively safe for the majority of the population but still represents a serious risk factor for those prone to developing IBD or other chronic inflammatory diseases.”
Substances like sucralose which are primarily excreted in the feces (nonabsorbed) have generally been viewed as harmless. “Appreciation of the pivotal role of the microbiota in health questions the latter assumption.”

My take: I think the influences on the microbiota are difficult to tease out. Thus, this study (in mice) indicates —don’t assume that nonabsorbed agents are harmless

Why Did the Young Woman’s Heartburn Keep Getting Worse?

Posted on June 12, 2018 by gutsandgrowth

Mystery NY Times Case: Why Did the Young Woman’s Heartburn Keep Getting Worse?

An excerpt:

The radiologist who read the scan made an interesting observation. In each of the three visits to the E.R., the patient’s blood had been tested. All three tests showed an elevated white-blood-cell count. That could suggest an infection — but in her tests a quarter of those white blood cells were a cell type known as eosinophils, which normally make up only a tiny fraction of the white blood cells in the circulation. ..

When the radiologist saw the elevated level of eosinophils, however, he recalled an unusual and relatively new disorder known as eosinophilic gastroenteritis (EGE). He added this rarity to the list of possible causes of the patient’s abnormal CT findings on his report…

EGE is thought to be an unusual type of allergic reaction to foods. Food exposure triggers the recruitment of eosinophils to the gut, but once they have a toehold, repeated exposure isn’t necessary to keep them there. The disorder was first described in a series of patients in the United States in 1993 but since then has been found to occur throughout the developed world. Because it’s a relatively new disease, and because our understanding of allergy is still emerging, it’s not well understood. As recognition of the disorder expands, so, too, do the number of cases. Patients are usually started on an elimination diet and given steroids to further suppress the immune system. An elimination diet — one in which the foods most frequently linked to allergic reactions, like milk, eggs and wheat, are not consumed — has been shown to be helpful up to 90 percent of the time.

Related blog posts:

Not Preparing for the Next Pandemic

Posted on June 11, 2018 by gutsandgrowth

A terrific commentary (Bill Gates, NEJM 2018; 378: 2057-60) explains how we are NOT preparing for the next pandemic and what we should be doing and why.

Key points:

There has been incredible progress in many areas of global health and infectious diseases. In fact, “child mortality has decreased by more than 50% since 1990.” HIV is no longer “a certain death sentence” and there has been progress with malaria.
Yet, “there is a significant probability that a large and lethal modern-day pandemic will occur in our lifetime.” Some recent events have alerted us to this risk, including swine flu in 2009, Ebola in 2014 as well as recent MERS (Middle East respiratory syndrome) and SARS (severe acute respiratory syndrome).
“We need better tools, an early detection system, and a global response system.”
“A simulation by the Institute for Disease Modeling shows what would happen if a highly contagious and lethal airborne pathogen, like the 1918 influenza, were to appear today. Nearly 33 million people worldwide would die in just 6 months.” (see below)
Vaccine development holds some promise to protect against many pathogens. One step to help with vaccines has been a public-private venture, Coalition for Epidemic Preparedness Innovations (CEPI).
Vaccines alone are not enough as they take time to stimulate immunity and often not enough people receive them. “So we need to invest in other approaches, such as antiviral drugs and antibody therapies that can be stockpiled.”

My take (borrowed): “”If it were a military weapon [threat], the response would be to de everything possible to develop countermeasures. In the case of biologic threats, that sense of urgency is lacking. But the world needs to prepare for pandemics in the same serious way.”

DDW18 Tweets

Posted on June 10, 2018 by gutsandgrowth

What to Do For Friends and Family Who Are Depressed

Posted on June 9, 2018 by gutsandgrowth

In light of the troubling news of recent suicides, I wanted to reference a recent NY Times article which provides useful guidance on What to Do When a Loved One is Severely Depressed

Here are the key points/excerpts:

Don’t underestimate the power of showing up
Don’t try to cheer him up or offer advice

“Your job as a support person is not to cheer people up. It’s to acknowledge that it sucks right now, and their pain exists,” she said…

Instead of upbeat rebuttals about why it’s not so bad, she recommended trying something like, “It sounds like life is really overwhelming for you right now.”

It’s O.K. to ask if she is having suicidal thoughts
Take any mention of death seriously

If this person is seeing a psychiatrist or therapist, get him or her on the phone…

If that’s not an option, have the person you’re worried about call a suicide prevention line, such as a 1-800-273-TALK, or take her to the hospital emergency room; say aloud that this is what one does when a loved one’s life is in danger.

Make getting to that first appointment as easy as possible

You alone cannot fix this problem, no matter how patient and loving you are. A severely depressed friend needs professional assistance from a psychologist, psychiatrist, social worker or another medical professional.

Take care of yourself and set boundaries

Still, just because someone is depressed is not a reason to let their abusive behavior slide. Set clear boundaries with straightforward language such as, “It sounds like you’re in a lot of pain right now. But you can’t call me names.”..

It’s O.K. not to be available 24-7, but try to be explicit about when you can and cannot help. One way to do this, Ms. Devine advised, is to say: “I know you’ve been really struggling a lot, and I really want to be here for you. There are times that I physically can’t do that.”

Remember, people do recover from depression

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.

Also, it is worth noting that the suicide rate has been increasing.

PPIs NOT Linked to Cognitive Decline/Dementia & PPIs NOT Linked to Heart Attacks

Posted on June 8, 2018 by gutsandgrowth

In a prospective study (M Wod et al. Clin Gastroenterol Hepatol 2018; 16: 681-89), data on middle-aged (n=2346, 46-67 yrs) and older individuals (n=2475) were collected in the Longitudinal Study of Aging Danish Twins. This study showed that there was no difference in cognitive decline between PPI users and non-users.

The second study (SN Landi et al. Gastroenterol 2018; 154: 861-73) used a large administrative database and reviewed more than 5 million new users of prescription PPIs and prescription H2RAs. The authors found no significant difference in myocardial infarctions (MIs) between PPIs and H2RAs over a 12 month period.

Related blog posts:

Lots of Allergy & Autoimmunity Issues Following Solid Organ Transplantation

Posted on June 7, 2018 by gutsandgrowth

A recent retrospective cross-sectional cohort study (N Marcus et al. J Pediatr 2018; 196: 154-60, editorial page 10) identified 273 transplant recipients with a median followup of 3.6 years. This cohort included 111 liver transplant recipients, 103 heart transplant recipients, 52 kidney transplant recipients, and 7 multivisceral transplant recipients.

Key findings:

92 (34%) developed allergy or autoimmunity after transplantation.
Allergic problems included eczema (n=44), food allergy (n=22), eosinophilic gastrointestinal disease (n=11), and asthma (n=28)
Autoimmunity problems developed in 6.6% (18) including autoimmune cytopenias (n=10). Two patients died due to autoimmune hemolytic anemia and hemophagocytic lymphohistiocytosis.
Allergic problems typically developed during the first year after transplantation and rarely after 5 years following transplantation.
~20% required a change in immunosuppression
~50% improved with time

In the editorial, the Dr. Helen Evans notes that the increasing reporting of atopic/allergic disorders could be due to recognition but could also be due, in part, to the widespread adoption of tacrolimus instead of cyclosporine for immunosuppression.

My take: Many have said that organ transplantation, which is life-saving, substitutes one problem for another. This is an example of an additional burden, often related to immunosuppression, that patients and families have to manage afterwards.

Chattahoochee River, Island Ford

Low-Value Care: IBD Serologies for Diagnosis of IBD

Posted on June 6, 2018 by gutsandgrowth

A recent high-value care series (MD Long, BE Sands. Clin Gastroenterol Hepatol 2018; 16: 618-20) explains why “clinicians should not use IBD serologies as a test to diagnose inflammatory bowel disease.”

Here are the key points:

“Benoir et demonstrated that a 7-marker serology panel had a lower predictive value than routine laboratory tests in diagnosis of IBD among symptomatic pediatric patients.”
“Studies on the accuracy of these serologies for diagnosis included populations with a high prevalence of IBD (42%-62%), rather than the low-prevalence populations in primary care settings” (or even in for routine GI office visits)…”When the disease is rare, a greater proportion of the positive tests represent false positives and the PPV [positive predictive value] is low.”
The authors also recommend against using serologies to predict a more aggressive course because “no data exist that modifications based on these serologies improve outcomes.”

My take: When I highlight this article, there is an element of confirmational bias as I have held a dim view of their value for a long time. While there is some academic interest in IBD serology results, to me, it is a disturbing trend to see patients with nonspecific abdominal pain referred who have already had these serological markers.

Increased Organ Availability for Transplantation Related to Opioid Epidemic

Posted on June 5, 2018 by gutsandgrowth

A letter to the editor (MR Mehra et al. NEJM 2018; 378: 20: 1943-45) provides a perspective on the increasing availability of organs for transplantation from drug overdoses/opioid epidemic from 2000 to 2016.

Key findings:

“The drug-abuse epidemic has been associated with a sharp increase in the recovery of organs from brain-dead donors in the United States but not in Europe. “
“The U.S. data indicate that survival among recipients from donors who died from drug intoxication is similar to survival among recipients from donors who died from other causes.”

My take: Opioid use is more likely to place one at risk for needing a liver transplantation due to increase acquistion of hepatitis C infection and is more likely to make a donor available due to drug overdoses.

Related blog posts: