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.

EPA OK with “Polluting Developing Brains”

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For those unable to grasp the fact that the current EPA director is harmful to our health, it may not be their fault.  According to this commentary (VA Rauh. N Engl J Med 2018; 378:1171-1174), organophosphates like chlorpyrifos have likely resulted in the loss of ~17 million IQ points among 0 to 5 year olds; by extrapolation, this affects those older than 5 years too. Link: Polluting Developing Brains — EPA Failure on Chlorpyrifos

An excerpt: The regulatory plan developed by the U.S. Environmental Protection Agency (EPA) just before the 2016 elections was excellent: revoke all allowances for foods to contain residue of the organophosphate insecticide chlorpyrifos (“food tolerances”), essentially prohibiting agricultural and all remaining uses of the chemical… A total ban was the logical conclusion after decades of risk assessment showing increasing evidence of threats to human health, and children’s safety in particular…

However, the plan was scrapped in March 2017 by incoming EPA Administrator Scott Pruitt, who overrode the recommendation of agency scientists to ban all commercial use of chlorpyrifos… this action essentially violates the EPA’s statutory duty to protect human health, ignoring explicit child health policy dating back to 1995 that requires all national public health standards to address the special vulnerability of infants and children…

Harmful effects of chlorpyrifos on the developing brain are hardly surprising, given that this chemical was initially developed to attack the nervous system by inhibiting neurotransmitters in the body. First introduced as nerve-gas agents during World War II, organophosphate chemicals were later repurposed by chemical companies as insecticides and other pesticides…

Among the most worrisome findings are the corroborative results from several prospective cohort studies of children, which show an inverse dose–response effect of prenatal exposure to chlorpyrifos on cognition at 7 years of age..

In fact, one review (assuming a population of 25.5 million children 0 to 5 years of age in the United States) calculates a total loss of 16.9 million IQ points due to exposure to organophosphates, of which chlorpyrifos is the most widely used..

Because adult occupational exposures to chlorpyrifos have been clearly linked to Parkinson’s disease, there is good reason to worry that early exposures may set in motion a pathogenic trajectory potentially leading to neurodegenerative disease…

The EPA …may be putting an entire generation of young brains in harm’s way.

Estimated Agricultural Use for Chlorpyrifos, 2015 (Preliminary).
Estimates are from the U.S. Geological Survey National Water-Quality Assessment Project.

Wilson’s Disease –Pediatric Guideline

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P Socha et al. JPGN 2018; 334-4. This ESPGHAN position paper makes recommendations for Wilson’s disease. This is a helpful paper, though the AASLD Wilson’s guideline is more comprehensive. A couple of pointers from the JPGN publication:

  • The authors recommend molecular testing if available and using liver copper measurement “if molecular testing is inconclusive”
  • Screen siblings of any new patients
  • Urinary copper excretion in the 200-500 mcg per 24 hours is consistent with adequacy of treatment
  • With treatment, liver function tests improve over 2-6 months. “If increased transaminases remain or relapse despite treatment, poor compliance should be suspected.”

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January 2018 -Sunrise in Sandy Springs

Eliminating Gluten Challenge for the Diagnosis of Celiac Disease

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Many patients receive a gluten-free diet (GFD) prior to a definitive diagnosis of celiac disease.  The diagnostic yield of serology can significantly decrease within a month after institution of a GFD.  A recent study (VK Sarna et al. Gastroenterol 2018; 154:886-96) has identified an HLA-DQ-Gluten Tetra

mer Blood test which can accurately identify celiac disease despite the implementation of a GFD.  This test quantifies HLA-DQ-gluten tetramer binding to T cells with flow cytometry. Key findings:

  • For patients receiving a GFD, the sensitivity was 97% and the specificity was 95% for the diagnosis of celiac disease
  • For patients not receiving a GFD, the sensitivity was 100% and the specificity was 90% for the diagnosis of celiac disease

My take: An accurate test to determine if celiac disease is present for those who have started a GFD would be quite helpful.  This HLA-DQ-Gluten Tetramer blood test still needs further validation in more patient populations. This test is NOT commerically-available at this time.

Morgan Falls

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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.

Chattahoochee river -Morgan Falls

Hepatitis C Infections Increasing -Tied to Opioid Crisis

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Just when it looked like new treatments could eliminate/cure hepatitis C virus (HCV), it turns out that with the opioid epidemic, HCV infections are increasing at a rapid pace (TJ Liang, JW Ward. NEJM 2018; 378: 1169-71).

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Estimated number of new Hepatitis B and Hepatitis C Infections in the U.S. from CDC Data.

POEM for Achalasia in Children

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Briefly noted: S Miao et al. JPGN 2018; 66: 257-62.  In this retrospective study, the authors examined the use of peroral endoscopic myotomy (POEM) in children.  They , describe a successful outcome in all 21 patients (range 11 months to 18 years).  Complications included subcutaneous emphysema (n=4), pneumoperitoneum (n=1), mediastinal emphysema ((n=4), pneumonia (n=1) and mucosal injury (n=1). The authors: “although Heller myotomy is still widely accepted as the standard treatment for achalasia in children, POEM …may provide a better treatment …due to less hospitalization, less trauma, …and long-term efficacy.”

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Amber Cove, Dominican Republic

Capsule Endoscopy More Sensitive than MRE for Crohn’s Disease

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Briefly noted: B Gonzalez-Suarez et al. IBD 24: 775-80.

In 47 patients with established (n=32) or suspected Crohn’s disease (n=15), MRE was first performed to exclude strictures and then subsequently capsule endoscopy (CE) (with patency capsule in 10 patients). Key finding: Small bowel lesions were found in 36 of 47 with CE compared with 21 of 47 with MRE (76.6% vs 44.7%, P=0.001)

Related blog post: Head-to-Head: Capsule endoscopy compared to colonoscopy

Time Will Tell: Granulomatous Upper GI Inflammation

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A recent retrospective study (K Queliza et al. JPGN 2018; 66: 620-23) describes seven patients with granulomatous disease in the upper GI tract who were diagnosed with ulcerative colitis.

This study examined patients at a single center between 2007-2016 with ages ranging from 2 years to 17 years.  Median time of followup is not provided.  Two patients required colectomy.  All patients had non-casseating granulomas identified in either the stomach or duodenum (or both) along with moderate to severe pancolitis.  All of the patients had extensive investigations, generally cross-sectional imaging (MRE or CT) or capsule endoscopy

Key point::

  • “The final classification of IBD was based on expert opinion from gastroenterologists, radiologists, and pathologists upon thorough review of the medical records.”

My take: This study highlights the confusion of the essentially binary classification of IBD into either Crohn’s disease or ulcerative colitis, when in fact there are hundreds of genetic mutations which give rise to inflammatory bowel disease.  Given that granulomas are a hallmark of Crohn’s disease and there are no pathognomic features of ulcerative colitis, only time will tell if these patients have an ulcerative colitis phenotype.  I wonder how many centers would take exception to this classification and describe these patients as ‘indeterminate’ colitis/IBDU (IBD unclassified).

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Lactobacillus rhamnosus GG Associated with Increased Necrotizing Enterocolitis in Observational Study

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A recent retrospective study (AF Kane et al. J Pediatr 2018; 195: 73-9) with 640 VLBW infants found that the probiobiotic, Lactobacillus rhamnosus GG (LGG), was associated with an increased risk of necrotizing enterocolitis (NEC).

LGG supplementation was started at a median age of 6 days at a dose of 2.5 to 5 x 10 to the 9th CFU/day.

Key finding:

  • LGG group had an aOR of 2.10 for developing NEC.  LGG group NEC incidence was 16.8% whereas NEC incidence was 10.2% prior to institution of LGG.

The authors note their findings are in contrast to findings from 38 randomized trials (10,520) which have found that probiotics lowered the risk of NEC.

My take: This study reinforces the need for further studies to identify which factors and probiotic strains are likely to lead to reduced rates of NEC.

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TPN Prior to Liver Transplantation for Biliary Atresia

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Briefly noted:

D Wendel et al. JPGN 2018; 66: 212-7.  This single center retrospective review examined patients who received home TPN prior to liver transplantation.   These 18 patients, which represented 41% of their entire transplant cohort of 44 between 2010-2015, all had biliary atresia. Key findings:

  • Malnutrition improved or resolved in all but one patient
  • 8 catheter-related infections were noted (3.8/1000 catheter days)
  • There were no deaths in patients receiving TPN

My take: While there is an increased burden of care with TPN, improved nutrition may improve long-term outcomes.

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Amber Cove, Dominican Republic

 

 

Joint Mobility –Not Associated with Increased Functional GI Disorders

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According to a recent study (M Saps et al. JPGN 2018; 66: 387-90), joint hypermobility is not associated with an increased risk of functional gastrointestinal disorders (FGIDs).

From a school-based study of 654 children from a public school in Cali, Columbia, 148 (22.6%) were identified as having an FGID. Among this group, 136 children participated in the study along with 136 age/sex-matched healthy controls. Joint laxity was assessed to establish a Beighton score.

Key finding:

  • There was no significant difference in joint laxity between the FGID group and the control group, with OR of 1.03.

The implication of this study is that previous associations between joint hypermobility (JH) and FGIDs could be due to selection bias at tertiary care centers.  Alternatively, “it is possible that the association between FGIDs and JH exists, but it is only limited to a subset of patients that consult at specialized clinics.”

My take: This article challenges the idea that JH increases the risk of FGID.  Based on this study, if JH is a risk factor, it is hard to detect in a general population.

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Amber Cove, Dominican Republic