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.

Gluten-Free for IBS-D?

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A recent study (I Aziz et al. Clin Gastroenterol Hepatol 2016; 14: 696-703) shows that a 6 week gluten-free diet reduced IBS-D symptoms in 29 of 41 (71%) patients.

  • The authors performed a prospective study with all patients receiving a gluten-free diet.  At 6 weeks, 21 of 29 who had responded to GFD continued GFD through 18 months followup.
  • One difference with this study compared to prior studies –these patients were irritable bowel syndrome with diarrhea and fulfilled Rome III criteria.  Celiac disease had been excluded with serology and histology; thus, these patients did not have “potential” celiac disease.
  • In addition to GI symptoms like abdominal pain, distention, and stooling problems, patients experienced improvement in mood, fatigue and quality of life.
  • The authors note that the response rate of 71% is much higher than they would have expected if the response was related solely to a placebo effect.

My take: This small study shows that a gluten free diet may be effective in improving the symptoms in many patients with IBS-D.  Other studies have shown that several other diets are effective as well.

Related blog posts:

IBS diagram

 

Tick Bites Can Lead to Allergy to Red Meat

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From NBC News: Tick Bite Linked to Rise in Red Meat Allergies

Excerpt:

A tick-related meat allergy has been quietly spreading across the southern and eastern U.S. over the past two decades, but in recent years the number of cases have steadily risen. A tick bite in some people can kick off a sensitivity to red meat that can result in symptoms such as itching, hives, swollen lips and breathing problems. The reaction can sometimes be life threatening. 

Terrific 8th grade graduation speech: 8th grader Nails Impersonations of presidential candidates

Five Year Data on Magnetic Device for GERD

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Here’s an abstract regarding the efficacy of a magnetic device for gastroesophageal reflux in adults:

Background & Aims

Based on results from year 2 of a 5-year trial, in 2012 the US Food and Drug Administration approved the use of a magnetic device to augment lower esophageal sphincter function in patients with gastroesophageal reflux disease (GERD). We report the final results of 5 years of follow-up evaluation of patients who received this device.

Methods

We performed a prospective study of the safety and efficacy of a magnetic device in 100 adults with GERD for 6 months or more, who were partially responsive to daily proton pump inhibitors (PPIs) and had evidence of pathologic esophageal acid exposure, at 14 centers in the United States and The Netherlands. The magnetic device was placed using standard laparoscopic tools and techniques. Eighty-five subjects were followed up for 5 years to evaluate quality of life, reflux control, use of PPIs, and side effects. The GERD–health-related quality of life (GERD-HRQL) questionnaire was administered at baseline to patients on and off PPIs, and after placement of the device; patients served as their own controls. A partial response to PPIs was defined as a GERD-HRQL score of 10 or less on PPIs and a score of 15 or higher off PPIs, or a 6-point or more improvement when scores on vs off PPI were compared.

Results

Over the follow-up period, no device erosions, migrations, or malfunctions occurred. At baseline, the median GERD-HRQL scores were 27 in patients not taking PPIs and 11 in patients on PPIs; 5 years after device placement this score decreased to 4. All patients used PPIs at baseline; this value decreased to 15.3% at 5 years. Moderate or severe regurgitation occurred in 57% of subjects at baseline, but only 1.2% at 5 years. All patients reported the ability to belch and vomit if needed. Bothersome dysphagia was present in 5% at baseline and in 6% at 5 years. Bothersome gas-bloat was present in 52% at baseline and decreased to 8.3% at 5 years.

Conclusions

Augmentation of the lower esophageal sphincter with a magnetic device provides significant and sustained control of reflux, with minimal side effects or complications. No new safety risks emerged over a 5-year follow-up period. These findings validate the long-term safety and efficacy of the magnetic sphincter augmentation device for patients with GERD. ClinicalTrials.gov no: NCT00776997.

It is important to note the following:

  1. Symptom control was not different between the magnetic sphincter and surgery
  2. The target population met the inclusion criteria: typical GERD symptoms, abnormal esophageal acid exposure by pH monitoring, partial response to daily PPI, and absence of large hiatus hernia or severe esophagitis

Related blog post:  Stopping reflux with magnets | gutsandgrowth

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NYT: Educate Your Immune System

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A recent commentary updates the concept of the hygiene theory and how our lack of exposures to a ‘dirtier’ environment when we are younger can make us more prone to autoimmune diseases, including celiac disease, diabetes, and multiple sclerosis.

Here’s the link: Educate Your Immune

Here’s an excerpt:

People living just over the border in Russian Karelia, as the region is known, have the same prevalence of genes linked to autoimmune disease [as in Finland]. They also live at the same latitude and in the same climate. And yet they have a much lower vulnerability to autoimmune disease. Celiac disease and Type 1 diabetes occur about one-fifth and one-sixth as often, respectively, in Russian Karelia as in Finland. Hay fever and asthma, allergic diseases that also signal a tendency toward immune overreaction, are far less common.

So in a follow-up study, the results of which appeared last month in the journal Cell, Dr. Xavier and his colleagues followed 222 children who were genetically at risk of developing autoimmune diabetes. The newborns were equally divided among Finland, Russia and Estonia, where the prevalence of Type 1 diabetes is on the rise, but still well below Finland’s.

Autoimmune diabetes can be predicted, to some degree, by the appearance of certain antibodies in the bloodstream that attack one’s own tissues. After three years, 16 Finnish children and 14 Estonian children had these antibodies; only four Russian children did. And when the scientists compared the children’s microbiomes in the three countries, they found stark differences. A group of microbes called bacteroides dominated in Finnish and Estonian infants. But in Russia, bifidobacteria and E. coli held sway….

Russian kids have more fecal oral infections, such as hepatitis A, suggesting more sharing not only of pathogens, but of microbes that may benefit health. And previous studies have found that Russian homes harbor a richer and more diverse community of microbes than Finnish ones….

The world today is very different from the one our immune system evolved to anticipate — not just in what we encounter, but in when we first encounter it. Preventing autoimmune disorders may require emulating aspects of that “dirtier” world.

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Best Fecal Marker for Crohn’s Disease: Calprotectin

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A recent study (EK Wright et al. Inflamm Bowel Dis 2016; 22: 1086-94) collected data from 135 participants in a prospective, randomized, controlled trial aimed at preventing postoperative Crohn’s disease (CD) recurrence.  As part of this study, serial stool collections enabled comparison of fecal markers: calprotectin (FC), lactoferrin (FL) and S100A12 (FS).

FC was the optimal marker and was superior to CRP and CDAI. Table 4 provides a list of sensitivity, specificity, PPV, and NPV for each of the fecal markers at various cutoffs.

For FC, using the optimal cutoff of 135 mcg/g, the sensitivity was 0.87, specificity was 0.66, PPV was 56%, and NPV 91%.  A lower cutoff (50 mcg/g) improved sensitivity to 0.96 and NPV to 94%; whereas a higher cutoff (200 mcg/g) lowered the sensitivity to 71% but improved the specificity to 0.74 along with raising the PPV% to 59%.

My take: While the yield of a test changes based on the population examined, this report indicates that it is likely that calprotectin would outperform the other fecal inflammatory markers in most settings.

Related blog posts:

Briefly noted: G Gale et al. Inflamm Bowel Dis 2016; 22: 1071-77.  This report describes more extensive disease when there is concomitant orofacial granulomatosis with Crohn’s disease.

Paris from Postcards

Paris from Postcards, Vik Muniz

ParisCaption

Identifying IBD Years Before Symptoms

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A while back there was a movie called “Minority Report.”  The movie’s premise was that crimes could be predicted and stopped before they occurred.  A recent study (P Lochhead et al. Clin Gastroenterol Hepatol 2016; 14: 818-24) presents intriguing data suggesting a similar scenario for inflammatory bowel disease (IBD).

The authors used a prospective, nested case control study of participants in the Nurses’ Health Study I and II. Median age of patients with Crohn’s disease (CD) (n=83) and ulcerative colitis (UC) (n=90) was 52.7 years and 50.4 years respectively. Key findings:

  • Median prediagnostic hsCRP levels (mg/L) were 2.3 in CD, 2.2 in UC and 1.5 in controls (n=344).
  • Median prediagnostic IL6 levels (pg/mL) were 1.7 in CD, 1.2 in UC, and 1.0 in controls.
  • Median time interval between blood collection and diagnosis was 6.6 years for CD and 6.8 years for UC.
  • There was increased odds for developing disease even after adjustment for potentially confounding variables like smoking.  This analysis held up even when excluding disease that developed within 2 years of sampling.

Overall, this study suggests that there is a significant population of patients with subclinical IBD which precedes the diagnosis by several years.  This report adds to a number of other studies showing potential “preclinical phase” of many diseases including rheumatoid arthritis and type 1 diabetes.

My take: It is fascinating that bloodwork can be abnormal years before clinical symptoms. However, as in “Minority Report” the problem will be with identifying a crime/disease that might never occur.

Unrelated –Chart Depicting Car Temps:

car temp

Why some kids are short & understanding linear growth

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If you want to explore the biological basis for short stature, then an excellent review (YH Jee, J Bacon. J Pediatr 2016; 173: 32-7) is worthwhile.

The article begins by explaining the reasons why linear growth is rapid in infancy, slows in childhood and accelerates in adolescence through a process of growth plate chondrogenesis.  In addition, the idea that growth plate fusion causes growth cessation is not accurate.  Fusion of the growth plate occurs because of growth cessation. In addition, in many with “catch-up growth” the “delay in maturation appears to be driven by subtle undernutrition due to diminished appetite.”

Altered Growth Plate Chondrogenesis:

  • Nutritional intake -excess and inadequate nutrient intake affects growth, often through modulation of endocrine hormones.  Overnutrition accelerates linear growth “but the adult height is not substantially affected.”
  • Hormones –thyroid hormones, growth hormone, IGF-1, androgen, and estrogen all positively regulate linear growth.  Glucocorticoids negatively regulate linear growth.
  • Inflammatory cytokines –these cytokines (including TNF-α, IL-6, IL-1β) negatively regulate chondrogenesis
  • Paracrine growth factors, Extracellular Matrix, Intracellular Proteins –local growth factors can be deficient in those with specific genetic mutations:  FGFR3 -achondroplasia, GNAS -Albright hereditary osteodystrophy, PTH1R -Blomstrand chrondrodysplasia, PTPN11 (& others) -Noonan, SHOX -Langer mesmeric dysplasia.  SHOX mutations accounts for 2-5% of children with formerly idiopathic short stature.  SHOX gene is also involved in Turner syndrome short stature. More listed in their Table (pg 35).

My take: It is cool to see the evolved understanding of the various factors affecting stature.  While the authors conclude that exome sequencing will alter the diagnostic approach to children with severe short or tall stature, it seems that a genetic panel would be quite practical and less expensive than many endocrinological evaluations.

Related blog post: Here’s Why Biologic Therapy for Crohn’s Helps Adolescents …

Imodium

IBD School Videos for Patients and Families

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While these “IBD School” YouTube videos have been around for several years, I only became aware of them in the past few months.  I think they are good patient education resources.

Here are some links to a few of them:

There are a lot of these videos including the following:

My take: these videos are generally ~4 minutes and a good way to get a lot of information on IBD pretty quickly.

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What is Missing in Doctors’ Toolkits

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An excellent editorial provides insight into the complex interaction between social problems and health issues.  In this age of widespread information availability, the biggest problems are not solved by knowing everything and memorizing facts.  Solving problems with teamwork and identifying resources are increasingly important.

Here’s the link: NY Times: Giving New Doctors the Tolls They Need

Here’s an excerpt:

But consider the skills I would need to be more effective in just this one clinic session: understanding social issues that contribute to health; marshaling support resources like case management, social work and rehabilitation centers; exploring my patients’ values and goals and encouraging behavior change; leading interdisciplinary care teams; employing new technologies and methods of patient engagement like telemedicine; and appreciating how health systems fit together to influence an individual patient’s care — from home care and community centers to clinics and hospitals. None have traditionally been emphasized in medical education — and, unsurprisingly, doctors in training like myself are often ill-equipped to practice in today’s health care environment…

The new Dell Medical School at the University of Texas, Austin, which enrolls its first class in June, is hoping to revolutionize medical education. The school plans to focus on helping students understand how health systems, communities and social issues contribute to individual health through a variety of innovative methods.

Instead of traditional lecture halls, Dell’s students will learn in collaborative workspaces with a curriculum that emphasizes team-based management of patients. They’ll take weekly classes with pharmacy, nursing, social work and engineering students. Dell’s “Innovation, Leadership and Discovery” program affords students an entire year to pursue projects related to population health and delivery system redesign.

Dell also features a unique collaboration with the university’s College of Fine Arts — known as the Design Institute for Health — to bring design thinking to health care. Here students will learn to think about everything from better hospital gowns and more hospitable hospital rooms to how patients access services online and how to make waiting rooms obsolete.

A representative case, associated with this figure of intestinal histology, of the complexity: a lady with psychosis associated with celiac disease is not adherent with her gluten free diet

A representative case of the complexity referred to in this blog post: NEJM 2016; 374: 1875-83.  This figure of intestinal histology shows damaged surface epithelium.  This is from a lady with new-onset psychosis associated with celiac disease who is not adherent with her gluten free diet