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.

Pancreatitis Update (Part 2)

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Our group received a very helpful update on pancreatitis from Maisam Abu-El-Haija (GI) and Jaime Nathan (surgery). These notes focus on the surgical perspective.  My notes may include some errors in transcription and errors of omission. Some pictures of the slides are included below as well.

Key points:

  • Several surgical procedures can be considered in chronic pancreatitis.  Prior surgical procedures, though, could reduce islet cells if TPIAT needed later.
  • TPIAT –Cincinnati experience: 17 cases in last 2 years.  Highly selected group. Operation time takes about 10 hours (or more).  GJ tube placed due to anticipated poor gastric emptying for 4-6 weeks. Fevers expected during 1st post-operative week due to systemic inflammatory response. ~15% of children remain on opioids after TPIAT, likely due to long-standing problems prior to TPIAT.
  • Post-TPIAT care: PERT, vitamins, insulin (may wean off).  During 1st year, anticoagulation, hydroxyurea/aspirin (if high platelets), and penicillin prophylaxis.  Prior to TPIAT, patients receive vaccines (due to anticipated splenectomy).

Related blog post:

Pancreatitis Update (part 1)

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Our group received a very helpful update on pancreatitis from Maisam Abu-El-Haija (GI) and Jaime Nathan (surgery). My notes may include some errors in transcription and errors of omission. Some pictures of the slides are included below as well.

Key points:

  • About 30% of acute pancreatitis patients have a 2nd bout of pancreatitis. Obesity is a risk factor for recurrence.
  • There has been a recent increase in incidence of acute pancreatitis.
  • Cincinnati has a gene panel to examine the four most common mutations which cause hereditary pancreatitis (PRSS1, SPINK1, CFTR, and CRTC) along with 6 other relevant genes. (28 day turnaround) In addition, there is a pancreatitis insufficiency panel.
  • Discussed screening for pancreatic insufficiency.  Directly measuring pancreatic enzymes are more sensitive for early insufficiency, but may be unnecessary if good growth and normal stool elastase.
  • There are NO proven medical/dietary therapies to prevent recurrent or chronic pancreatitis and eliminate pain symptoms.

Related blog posts:

FPIES Guidelines

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Recently, international consensus guidelines (A Nowak-Wegrzyn et al. J Allergy Clin Immunol 2017; 139: 1111-26) for the diagnosis and management of food protein-induced enterocolitis (FPIES) have been published.

The report starts with a review of epidemiology and diagnosis. Table 1 outlines features:

  • early vs. late: <9 months or >9 months
  • severity: mild-to-moderate =repetitive emesis with or without diarrhea, mild lethargy, severe =repetitive projectile emesis, pallor, lethargy, dehydration, hypotension
  • timing: acute vs chronic.  Acute occurs with intermittent exposures with emesis 1-4 h following exposure. Chronic occurs with repetitive food exposures (eg. formula in young infants)
  • IgE positivity: classical FPIES is IgE negative. Atypical FPIES is IgE positive

Some recommendations:

  • #4. “Consider specific IgE testing of children with FPIES to their trigger food because comorbid IgE-mediated sensitization to triggers, such as CM [cow’s milk], can infer a greater chance of persistent disease.”
  • #8. Conduct food challenges “in patients with suspected FPIES in medically supervised settings in which access to rapid fluid resuscitation is available and prolonged observation can be provided, if necessary.”
  • #14. Do not routinely obtain endoscopic evaluation as part of the evaluation of FPIES.
  • #17. Acute FPIES should be considered a medical emergency. “Approximately 15% of patients can have hypovolemic shock.”
  • #19. Consider ondansetron treatment as an adjunct (if >6 months of age)
  • #21. Do not recommend routine maternal dietary elimination of offending triggers while breast-feeding if the infant is asymptomatic.
  • #23. FPIES can occur to multiple foods.  “The majority of children (65% to 80%) have FPIES to a single food, most commonly CM.”  In one study, 5% to 10% of children reacted to more than 3 foods.
  • #26. Use hypoallergenic formula in infants who can no longer breast-feed and are given a diagnosis of FPIES caused by CM. Most will tolerate extensively hydrolyzed formulas; some may require an amino acid based formula
  • #29. Reviews natural history.  “The age of CM tolerance appears to be around 3 years” but there has been variability in reports. For FPIES due to grains, average age of tolerance is 35 months and other solid foods is 42 months.  The average age for soy is 12 months (later in some studies), for rice 4.7 years and 4.0 years for oats. For CM-FPIES with positive SPT response, a much protracted course has been reported, with older age of tolerance (~13.8 years)

Table III lists a differential diagnosis for FPIES and distinguishing features.  This list includes gastroenteritis, necrotizing enterocolitis, anaphylaxis, food aversions, inborn errors of metabolism, cyclic vomiting/neurologic disorders, gastroesophageal reflux, Hirschsprung’s enterocolitis, eosinophilic gastroenteritis, celiac disease, immune enteropathies/IBD, intestinal obstruction, and primary immune deficiencies.  Not listed on this table, but worth a mention, would be medical child abuse (aka Munchausen syndrome by proxy).

With regard to inborn errors of metabolism, these include urea cycle defects, hereditary fructose intolerance, hyperammonemic syndromes, Beta-oxidation defects, proprionic/methylmalonic academia, mitochondrial defects and others. Typically, features could include developmental delay, neurologic manifestations, organomegaly, and in some reaction to fruits.

Table IV specifies diagnostic criteria with the major criteria for acute FPIES: vomiting 1- to 4-h period after ingestion of the suspect food and absence of classic IgE-mediated allergic skin or respiratory symptoms.  Minor criteria include extreme lethargy, pallor, need for emergency room evaluation/IV fluids, and diarrhea in 24 h (usually 5-10 h).

Table VI details management of FPIES.  With moderate bouts, IV fluids with 20 mL/kg normal saline is recommended.  For severe episodes, “consider administering intravenous methylprednisolone, 1 mg/kg; maximum 60-80 mg/dose” in addition to fluid resuscitation.

Table IX provides empiric guidelines for selecting weaning foods in infants with FPIES.  The recommendations need to be considered based on whether the infant has shown tolerance for a number of foods, which can indicate the acceptability of a more liberal approach.  Age-specific guidance:

4-6 months:

  • Begin with smooth, thin purees and progress to thicker purees
  • Lower-risk foods: vegetables, broccoli, cauliflower, parsnip, turnip, pumpkin
  • Moderate-risk: squash, carrot, white potato, green bean
  • Higher-risk: sweet potato, green peas

6-8 months:

  • Continue to expand vegetables and fruits; in breast-fed, high-iron foods and/or supplemental iron are needed (1 mg/kg/day)
  • Lower-risk: fruits, blueberries, strawberries, plum, watermelon, peach, avocado
  • Moderate-risk: apple, pear, orange
  • Higher-risk: banana

8-12 months:

  • Offer soft-cooked and bite-and-dissolve textures
  • Lower-risk: high iron foods, lamb, fortified quinoa, millet
  • Moderate-risk: beef, fortified grits, corn cereal, wheat, barley
  • Higher-risk: fortified infant rice and oat cereals

12 months:

  • Offer tolerated table foods: chopped meats, soft vegetables, grains
  • Lower-risk: tree nuts
  • Moderate-risk: peanut, other legumes (besides green pea)
  • Higher-risk: milk, soy, poultry, egg, fish

Overall, with regard to food introduction: While children with FPIES have increased reactions to other foods, “current early feeding guidelines do not recommend delay in introducing complementary foods past 6 months of life because of FPIES. A practical ordering for introducing solids at about 6 months of age at home could start with fruits and vegetables.”  For infants with history of severe reactions, “supervised (eg. in-office) introduction can be considered…and prevent unnecessary avoidance.”  As with new foods in the home setting, starting with small amounts is recommended and then gradual build up in serving size.

Related blog post: SEED Journal Club: FPIES

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.

 

 

More IBD Cases Than Ever in Young Canadian Children

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Summary of recent article (Link to full study: Benchimol EI, et al. Am J Gastroenterol. 2017;doi:10.1038/ajg.2017.97) by Healio Gastroenterology: IBD incidence rapidly increasing in young Canadian children

An excerpt:

To evaluate the recent incidence, prevalence and trends in childhood-onset IBD in Canada, Benchimol and colleagues used health administrative data from five provinces to identify children aged younger than 16 years who were diagnosed with IBD between 1999 and 2010. During this period, 3,462 children were diagnosed with Crohn’s disease, 1,382 with ulcerative colitis and 279 with unclassifiable IBD, for an overall IBD incidence of 9.68 (95% CI, 9.11-10.25) per 100,000 children.

Throughout the study period, the annual percentage change in overall IBD incidence remained statistically stable, increasing by just 2.06% per year, but the incidence increased significantly among children aged younger than 5 years, rising by 7.19% per year.

Further, the annual percentage change in the prevalence of IBD increased significantly throughout the study period (4.56%), and at the end of the study period IBD prevalence was 38.25 (95% CI, 35.78-40.73) per 100,000 children.

The investigators noted their findings confirmed the predominant form of pediatric-onset IBD was Crohn’s disease, and that more boys were affected than girls.

My take: While Canada has high prevalence of IBD, I expect that there will be similar trends in epidemiology in multiple regions in young children.  When one looks at the increases in IBD prevalence over the last 100 years (see previous post) and the emergence of IBD in non-Western countries, it is quite alarming.

Also, last week a blog post discussed hepatic problems associated with IBD (Liver problems with IBD): here is full article text link: Hepatic Issues and Complications Associated with IBD

Related blog posts:

Prevent HPV

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The CDC currently recommends HPV vaccine at 11-12 years of age.  HPV Vaccine Information

Here’s why: NY Times: Close to Half of Americans with HPV

An excerpt:

More than 42 percent of Americans between the ages of 18 and 59 are infected with genital human papillomavirus, according to the first survey to look at the prevalence of the virus in the adult population.

The report, published on Thursday by the National Center for Health Statistics, found that high-risk strains of the virus — a cause of cervical and vaginal cancers, and cancer of the penis, as well as cancers of the anus and throat in both sexes — infect 25.1 percent of men and 20.4 percent of women.

The virus is transmitted by skin to skin contact; people who are infected may pass the virus to sexual partners…

“If we can get 11- and 12-year-olds to get the vaccine, we’ll make some progress,” Dr. McQuillan said. “You need to give it before kids become sexually active, before they get infected. By the time they’re in their mid-twenties, people are infected and it’s too late. This is a vaccine against cancer — that’s the message.”

Related blog post: Latest Vaccine Recommendations

Image Only: Candida Esopagitis

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In a patient who presented with trouble swallowing, his endoscopy showed candida esophagitis.  “Oral antifungal therapy was initiated in the patient, and within 2 weeks after starting therapy, his pain on swallowing was reduced. A repeat endoscopy performed 12 weeks after the initiation of antifungal therapy showed a marked reduction in the number and severity of esophageal lesion.”

Immigrant Doctors Blocked by New Rules Too

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With the U.S. government’s heightened emphasis on stopping immigration into the U.S., there have been noted declines in border crossings; however, it is anticipated that there will be billions in lost income in reduced tourism coincident with the implementation of these policies.

Along with the efforts to curb illegal immigration, new related policies may result in a significant decline in foreign medical graduates allowed to stay in the U.S. through expedited processing of H-1B visas.  This is likely to further strain the care available in rural communities.

From CNN Money: What Trump’s latest H-1B Move Means for Workers and Business

An excerpt:

Thousands of doctors from abroad need H-1B visas to continue working in the U.S. after the expiration of their J-1 visas — which permit them to complete a residency program…

Once they complete their residency, physicians can either return to their home country for two years before becoming eligible to reenter the U.S. through a different immigration pathway, such as an H-1B visa, or they can apply for a J-1 visa waiver.

In the last 15 years, H-1B visas have allowed 15,000 foreign doctors to come to American to work in underserved communities.

“The lack of premium processing would mean that there would be a delay for the doctors to start working in the communities they wish to serve, which have a lack of physicians in the first place,” said Ahsan Hafeez, a doctor who is in Pakistan awaiting approval of his H-1B so he can begin working in Arkansas.

From Internal Medicine News: Foreign doctors may lose US jobs after visa program suspension

An excerpt:

Starting April 3, U.S. Citizenship and Immigration Services (USCIS) is temporarily suspending its expedited processing of H-1B visas, a primary route used by highly skilled foreign physicians and students to practice and train in the United States…

In the meantime, many foreign medical students and physicians will lose top training spots and jobs as their H-1B applications linger in the system, said Jennifer A. Minear, a Richmond, Va.–based attorney and national treasurer for the American Immigration Lawyers Association.

“As a practical matter, the percentages of physicians coming into the U.S. who are accepted into residencies or fellowships, those are the top of the top for medical graduates around the world,” Ms. Minear said in an interview. “Most of them who stay afterward wind up working in underserved areas of the United States. It really doesn’t make much sense as a policy matter to create obstacles to attracting those people to the United States that would prevent them from getting here, obtaining U.S. education, and then remaining in the U.S. and providing urgently needed care to populations that would otherwise go without.”

Related blog posts:

Liver Problems with Inflammatory Bowel Disease

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A recent review (Full text: LJ Saubermann et al. JPGN 2017; 64: 639-52)  discusses the hepatic issues and complications associated with inflammatory bowel disease.

Key topics:

  • Primary Sclerosing Cholangitis (PSC)
  • Autoimmune Hepatitis (AIH)
  • Autoimmune Sclerosing Cholangitis (ASC)
  • Portal Venous Thrombosis/hypercoagulability
  • Cholelithiasis (more common in Crohn’s disease if diseased terminal ileum)
  • Viral hepatitis
  • Drug-Induced Liver Disease
  • Fatty Liver disease

Many of these topics have been discussed previously on this blog.  A couple of pointers in this review:

PSC:

  • Greater risk of colorectal carcinoma
  • IBD-PSC patients are at higher risk for pouchitis
  • GGT of >252 U/L “was highly sensitive (99%) and had good specificity (71%) for PSC” [or ASC]
  • The authors recommend “screening all newly diagnosed patients with IBD with ALT and GGT
  • Immunosuppressive therapy is NOT effective
  • Vancomycin therapy is currently being tested (clinical trials: NCT02137668 & NCT01802073)

AIH:

  • Less frequent in IBD patients than PSC
  • Most common treatment is prednisone/azathioprine
  • 40-80% of children have cirrhosis at AIH diagnosis, but “progression to end-stage liver disease is rare and …with appropriate treatment, 80% of patients achieve remission.”

ASC:

  • ASC is an overlap syndrome between AIH and PSC
  • “It is important that children with IBD and apparent AIH are routinely investigated for evidence of biliary disease with MRCP”
  • “ASC responds to the same immunosuppressive combination therapy used for AIH”

HAV/HBV Immunization:

  • HAV vaccination is effective in patients with IBD…although the rate [seroconversion] was significantly lower” in patients receiving anti-TNF therapy (92.4% vs 99.1% in one study).
  • In those needing HBV immunization: “One strategy evaluated to improve HBV immunity in adults with IBD is an accelerated course with double vaccine doses at 0, 1, and 2 months.”

Methotrexate (MTX):

  • “The extent of histological features of hepatotoxicity secondary to long-term MTX use in IBD has been infrequently described; however, the inicdence of significant abnormal histological findings appears to be rather low.”

My take: This article is a good starting point for liver-related issues in IBD.  For concerns regarding medications, the NIH livertox website is more useful and much more comprehensive.

Related blog entries:

DILI:

PSC:

AIH:

 

 

Increasing Incidence of Hepatocellular Carcinoma in the U.S.

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A recent study (DL White et al. Gastroenterol 2017; 152: 812-20) provide data showing a striking increase in the incidence of hepatocellular carcinoma (HCC). Using data from the US Cancer Statistics Registry which covers 97% of U.S. population, the authors found the following:

  • HCC incidence rose from 4.4 per 100,000 in 2000 to 6.7 per 100,000 in 2012
  • The annual rate of increase was 4.5% from 2000-2009, but then 0.7% annually from 2010-2012
  • The greatest increase occurred in 55-59 year olds (8.9% annually) and 60-64 year olds (6.4% annually)

The main HCC risk factors are HCV, HBV, and alcoholic liver disease, though obesity-associated HCC is emerging as an important risk factor as well.  The highest rates of HCC are seen in southern and western states, with Texas having the highest rates overall.  The high rate in Texas is in part due to the higher rates of HCC in Hispanics.

Overall, the authors indicate that the rising HCC rates are most closely tied to the peak HCV cohort (1945-65) and speculate that the arrival of direct-acting antivirals may help. At the same time, this HCV cohort is composed “disproportionately [of] minorities and of lower socioeconomic status” and may have less access to these advances in treatment.  Furthermore, in states like Texas which did not adopt Medicaid expansion as part of the Affordable Care Act, there are more uninsured patients who will be less likely to identify preceding risk factors for HCC.

My take: Perhaps in 20 years, we will see HCC incidence maps that are improving as HCV treatments become more widely available.  This presumes that other HCC risk factors, including obesity and alcohol, do not worsen significantly.

Related blog posts:

Safety of Long-term Adalimumab in Pediatrics; Weighted PCDAI

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A recent study (W Faubion et al. Inflamm Bowel Dis 2017; 23: 453-60) reports on the long-term safety/effectiveness of Adalimumab in pediatric patients entering the IMAgINE 2 trial (& who completed the 52 week IMAgINE 1 trial).

Patients with a PCDAI <10 were considered to be in remission and those who had a drop in PCDAI of 15 or more were considered to have had a treatment response.

Key findings:

  • Of the 100 patients enrolled in IMAgINE 2, 41% achieved remission and 48% had a treatment response at week 240.
  • >80% of patients were “able to discontinue use of corticosteroids.”
  • Adalimumab treatment was associated with growth normalization.
  • No new safety signals were identified.

While this study provides some reassurance regarding long-term adalimumab use, it should be noted that the instruments used to assess efficacy in this trial (& many others) are suboptimal.

A recent study (D Turner et al. JPGN 2017; 64: 254-60) showed that PCDAI (and several similar versions) had “poor correlation with calprotectin” and none of the PCDAI versions “can give a valid assessment of mucosal healing.”  This study had used prospectively collected data from the ImageKids study of 100 children with Crohn’s disease.  For the weighted PCDAI, the “best cut-off to identify endoscopic mucosal healing was <12.5 points” with a sensitivity of 58% and specificity of 84%.\

wPCDAI:

History: (recall 1 week):

  • Abdominal Pain  0=None, 10=Mild (does not interfere with activities, brief), 20=Moderate/Severe
  • Patient functioning 0=No limitations, 10=Occn difficulty with activities (below par), 20=frequent limitations
  • Stools per day 0=0-1 liquid stools, no blood, 7.5=up to 2 semiformed stools with blood or 2-5 liquid nonblood, 15=Gross bleeding or ≥6 liquid stools or nocturnal diarrhea

Laboratory

  • ESR 0 points if <20, 7.5 points if 20-50, 15 points if >50
  • Albumin 0 points if ≥3.5 g/dL, 10 points if 3.1-3.4 g/dL, and 20 points if ≤3.0 g/dL

Examination

  • Weight 0= Weight gain or stable or voluntary weight loss, 5=involuntary weight loss 1-9% or involuntary weight stable, 10= weight loss ≥10%
  • Perirectal Disease 0=None or asymptomatic tags, 7.5= 1-2 indolent fistula, scant drainage, no tenderness, 15=active fistula, drainage, tenderness or abscess

Extraintestinal Manifestatons: Fever for 3 days (≥38.5), definite arthritis, uveitis, erythema nodosum, or pyoderma gangrenosum

  • Points: 0=None, 10 ≥1

Total Score 0-125: ______________________

As compared with PCDAI, the weighted PCDAI drops height velocity, abdominal examination, and hematocrit.  Turner et al note “their exclusion does not mean that they have no role in reflecting disease activity, but that the other included items, as a whole, are inclusive of the contribution of the 3 items.” Also, the weighted PCDAI simplifies the “extraintestinal manifestation” into a simple choice; overall, this affects few scores due to the low frequency of these manifestations.

Related blog posts: