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.

IBD and Pregnancy

Posted on April 3, 2016 by gutsandgrowth

While managing inflammatory bowel disease during pregnancy is not within the scope of my practice as a pediatric gastroenterologist, it is helpful to have some familiarity with the issues.

Here’s a full-text link to AGA Guidelines: The Toronto Consensus Statements for the Management of Inflammatory Bowel Disease in Pregnancy

From the abstract, an excerpt:

Consensus was reached on 29 of the 30 recommendations considered. Preconception counseling and access to specialist care are paramount in optimizing disease management. In general, women on 5-ASA, thiopurine, or anti–tumor necrosis factor (TNF) monotherapy for maintenance should continue therapy throughout pregnancy. Discontinuation of anti-TNF therapy or switching from combination therapy to monotherapy may be considered in very select low-risk patients. Women who have a mild to moderate disease flare while on optimized 5-ASA or thiopurine therapy should be managed with systemic corticosteroid or anti-TNF therapy, and those with a corticosteroid-resistant flare should start anti-TNF therapy. Endoscopy or urgent surgery should not be delayed during pregnancy if indicated. Decisions regarding cesarean delivery should be based on obstetric considerations and not the diagnosis of IBD alone, with the exception of women with active perianal Crohn’s disease. With the exception of methotrexate, the use of medications for IBD should not influence the decision to breast-feed and vice versa. Live vaccinations are not recommended within the first 6 months of life in the offspring of women who were on anti-TNF therapy during pregnancy.

Better Discharge Planning Needed

Posted on April 2, 2016 by gutsandgrowth

An interesting commentary in NY Times: Most Dangerous Time at the Hospital? May be When You Leave

An excerpt:

One-fifth of Medicare beneficiaries are readmitted within 30 days of discharge, and one-third are readmitted within 90 days. One studyfound that 20 percent of patients have a complication within three weeks of leaving the hospital — more than half of which could have been prevented or ameliorated. Thankfully most complications are minor, but some can be serious, leading to permanent disability or death. All told, Medicare spends $26 billion annually on readmissions, $17 billion of which is for readmissions that are considered preventable…

there’s often a rush toward the end of hospitalization — when a patient wants to leave or a rehab bed opens up — leading to a haphazard set of final conversations, appointments and prescriptions. And because the exact time of discharge is uncertain, the doctor discharging a patient may not be the one who knows the patient best.

It’s also often not clear exactly when a patient should be discharged….

the remaining diagnostics and treatments are often completed after discharge. But this is where we struggle most. Research suggests direct communication between hospital doctors and primary care doctorsoccurs infrequently and that discharge summaries — detailed records of a patient’s hospital course — are often unavailable at a patient’s first post-hospital visit. Almost 30 percent of patients are discharged with a plan to continue workups after hospitalization, but more than one-third of these are never completed. Similarly, more than 40 percent of patients have lab tests pending at the time of discharge — with 10 percent requiring action—but most physicians remain unaware of them.

My take: This is indeed an area where checklists and attention should be focused. My top three:

Making sure a list of discharged medications is compared to admission medications
Identifying outstanding tests and arranging followup workup
Direct communication with outpatient physician(s)

Gibbs Gardens

Plumbism in Flint

Posted on April 1, 2016 by gutsandgrowth

A brief commentary (DC Berlinger NEJM 2016; 1101-3) provides a succinct summary of the medical story from Flint.

Historical:

Lead exposure has been known to be a hazard since the 1st century: Dioscorides “observed in his De Materia Medica that ‘lead makes the mind give way.'”
In 1723, an industrial hygiene act in the colonies prohibited the use of lead in the apparatus to distill rum due to being “unwholesom.”
“Water doesn’t receive as much attention as paint…but,…our word ‘plumbing’ derives from the Latin for lead, and lead poisoning is often called ‘plumbism.'”
The past 40 years, the U.S. has had dramatic reductions in blood lead levels. This is “one of the cardinal public health success stories.”
Lead in water poses unique problems because “it rarely originates in the source water. Rather, the problem usually lies near the point of consumption.”

“There is no safe level of lead, particularly for children”

Flint:

In 2014, “the city began taking its water from the Flint river rather than Lake Huron.” This was expected to save ~$100 per day; now, the cost of repairing infrastructure is estimated to be as high as $1.5 billion. Yet the Flint river water was “19 times as corrosive,” leading to more lead in the water.
The incidence of blood lead concentrations above the reference value of 5 mcg/dL rose from 2.4% to 4.9% from 2013 to 2015. “The increase was greatest, from 4.0% to 10.6%, among children in neighborhoods with the highest lead concentrations.”
Disadvantaged children already are at increased risk due to houses more likely to be in poor repair. In addition, they are at increased risk from higher levels of lead in solid/dust and lead paint.
“In coming years, parents will undoubtedly wonder, with anxiety and even guilt, whether their children’s every developmental stumble stems from this episode.”

My take (borrowed from author): “We have the knowledge required to redress this social crime…what we lack is the political will to do what should be done.”

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Gibbs Gardens

Eosinophilic Esophagitis: the Limits of “Clinical Remission”

Posted on March 31, 2016 by gutsandgrowth

Among patients with eosinophilic esophagitis (EoE), two issues are particularly vexing for families:

The recommendation to use endoscopy to assess response to treatment.
Using proton pump inhibitor (PPI) therapy as first line treatment when other therapies have higher response rates

To some extent, these issues are intertwined because PPI therapy works in less than half of patients and to determine this conclusively, an endoscopy is needed. Clearly, a reliable noninvasive biomarker would be quite helpful.

In the meantime, another study (CE Kuehni et al. Gastroenterol 2016; 150: 581-90, editorial 547-48) has shown that “clinical remission” has modest accuracy in detecting endoscopic and histologic remission in EoE.

This prospective observational study, performed between 2011-14, recruited 269 consecutive adults in Switzerland and U.S.. 67% male median age 39 years.

Key finding:

Of 111 who were in clinical remission (41.3%), only 79 (72%) and 75 (68%) were in endoscopic and histologic (<20 eos/mm2 which corresponds to <5 eos/median hpf) remission respectively.

My take (borrowed): “Physicians cannot rely on lack of symptoms to make assumptions about lack of biologic disease activity in adult EoE patients.”

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Gibbs Gardens

Guidelines on Functional Heartburn

Posted on March 30, 2016 by gutsandgrowth

How to diagnose and manage adults with functional heartburn: C Hachem, NJ Shaheen Am J Gastroenterol 2016; 111-53-61 (thanks to Ben Gold for reference).

Functional heartburn is defined as chronic symptoms of heartburn without objective evidence of reflux. The authors algorithm (Figure 2) recommends endoscopy for patients who have had heartburn that is unresponsive to a 2 month trial of PPI. If endoscopy is normal, pH-impedance study is recommended. If abnormal, impedance indicates nonerosive reflux disease. If normal and there is symptom correlation, this suggests esophageal hypersensitivity. If normal and there is no symptom correlation, this suggests functional heartburn (though authors note a role for motility testing in this circumstance in their algorithm).

Their conclusions:

Functional heartburn (FH) responds poorly to PPI therapy
The pathophysiology of FH is unknown but it is often associated with visceral hypersensitivity
Modulation of pain perception and alternative therapies (melatonin, TCA, SSRI, biofeedback, acupuncture, or hypnotherapy) may be helpful

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Which kids who aspirate need a gastrostomy tube?

Posted on March 29, 2016 by gutsandgrowth

While some may think all children who aspirate should have a gastrostomy tube, a recent study (ME McSweeney et al. J Pediatr 2016; 170: 79-84) indicates a more selective approach is appropriate.

This retrospective review of 114 patients (2006-2013) compared patients fed by gastrostomy tube (g-tube) and those who were fed orally. In their introduction, the authors note, “there has been a practice shift at many institutions away from g-tube placement and more toward continuing to feed children with aspiration orally.” All patients in the study had aspiration and/or penetration with thin liquids and/or nectar thick liquids on a videofluoroscopic swallow study (VFSS).

There were 61 who aspirated only thin liquids and 53 who aspirated thin and nectar thick liquids. All patients were divided into two groups: a g-tube group which did not have a preoperative trial of thickened feeds and an orally-fed group. Patients who had a fundoplication or post-pyloric feeds were excluded from this study.

Key findings:

There were no significant differences in admissions among those who aspirated thins compared with those that aspirated thin & nectar thick liquids.
Patients fed by gastrostomy were hospitalized more frequently (median 2 times compared to once with orally-fed) and for longer duration (median 24 days compared with median 2 days for orally-fed)
No differences in total pulmonary admissions were noted between gastrostomy-fed and orally-fed group

The authors advocate a trial of oral feeding in all children cleared to take nectar or honey thick liquids prior to g-tube placement.

While the authors note that g-tube placement did not result in fewer pulmonary admissions, in their discussion, they also reviewed studies which showed that fundoplication (with g-tube) was not associated with a reduced risk of respiratory complications and in fact, had higher rehospitalizations.

This current study, and previous studies, are limited by their design. Patients were not randomized and g-tube-fed patients may have had more comorbidities, biasing the results. The authors note that there were 11 children who failed oral thickening trials and needed g-tube placement. At the same time, there are substantial numbers of children whose swallow function improve. Also, the authors note that thickening agents have not been shown to lead to dehydration risk.

My take: the widespread availability of swallow studies has likely led to some children undergoing g-tube placement who may have been fine with ongoing orally-thickened feeds. Avoiding g-tube placement for children who can tolerate and thrive on thickened feeds is worthwhile.

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Super cool and its effects on the microbiome

Posted on March 28, 2016 by gutsandgrowth

A terrific review (ED Rosen. NEJM 2016; 374: 885-7) explains how cool temperature can alter the microbiome and the implications of this finding.

Background: mammals have at least two types of adipose tissue: “the familiar (and all too abundant) white fat that stores calories, and brown adipose tissue that dissipates energy…studies of mice have identified several drivers of the appearance of beige fat cells in white fat pads, a process known as ‘browning.'”

Reviewed study: Chevalier et al. Cell 2015; 163: 1360-74.

“This new work shows that cold exposure, like dietary change, provokes alterations in the gut microbiota of mice. Moreover, when cold-adapted flora are transferred to a germ-free animal, the recipient mouse loses fat mass and has improved insulin sensitivity…[they] are better able to defend their body temperature on being placed in the cold.”

“This new work shows that prolonged cold exposure induces a massive increase in the absorptive surface of the gut…cold causes a profound increase in the ratio of Firmicutes to Bacteroidetes”
“A companion article from the same group suggests that antibiotic therapy, which depletes gut microbiota, also induces browning and weight loss.”

My take: In totality, these studies demonstrate how multiple organs (in this case: adipose tissue and the gut) work together to face an environmental challenge. Furthermore, changes in the gut microbiome may be important for therapeutic advantage in many disease states including obesity, type 2 diabetes, short bowel syndrome, irritable bowel syndrome and many others. Now, that is cool.

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Hepatitis B Vaccine Protects for Up to 30 Years

Posted on March 27, 2016 by gutsandgrowth

From summary at GI & Hepatology News: Hepatitis B vaccine protection lasts 30 years

An excerpt:

Ninety percent of patients in a 1981 hepatitis B vaccine trial still had evidence of immune protection 30 years later, according to a study in the Journal of Infectious Diseases…
243 members of the original cohort who responded to the original primary vaccine series but received no subsequent doses during the 30-year period…
Of the patients tested, 125 (51%) had anti-HBs levels greater than or equal to 10 mIU/mL. Among participants with anti-HBs levels below 10 mIU/mL who were available for follow-up, 75 of 85 (88%) responded to a booster dose with an anti-HBs level greater than or equal to 10 mIU/mL at 30 days.
Read the full study in the Journal of Infectious Diseases (J Infect Dis. 2016 Jan 21. doi: 10.1093/infdis/jiv748).

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LEAP-ON Study: Early Peanuts Prevent Allergies

Posted on March 26, 2016 by gutsandgrowth

A followup study to the LEAP study (The Peanut Story -From NEJM Blog | gutsandgrowth) shows that early peanut exposure produces a durable protection from peanut allergies. NPR summary: Peanut Mush in Infancy Cuts Allergy Risk

Here’s an excerpt:

Researchers followed the kids for one additional year. The kids were between 5 and 6 years old during this follow-up period. It turned out, these high-risk kids’ tolerance to peanuts held up even if they stopped eating peanuts.

“A 12-month period of peanut avoidance was not associated with an increase in the prevalence of peanut allergy,” the authors write in the paper.

This is an important finding, because it wasn’t known whether the kids would need to maintain regular weekly consumption of peanuts in order to stave off developing an allergy…

But that doesn’t mean all parents should just rush in with the peanut mush. The guidance recommends that “infants with eczema or egg allergy in the first 4 to 6 months of life might benefit from evaluation by an allergist” — before they’re introduced to peanut-based foods.

Fajardo, Puerto Rico

Pharmaceutical Prescription Practices Tied to Pharmaceutical Payments to Doctors

Posted on March 25, 2016 by gutsandgrowth

A recent buzz has developed regarding a ProPublica study showing an association between the amount of money physicians receive from pharmaceutical companies and their likelihood of recommending brand (rather than generic) prescription drugs.

Here’s a link to the full story: Now There’s Proof: Docs Who Take Company Cash Tend to Prescribe More Brand-Name Meds

“The more money doctors receive from drug and medical device companies, the more brand-name drugs they tend to prescribe, a new ProPublica analysis shows. Even a meal can make a difference.”

Here’s a link to NPR’s summary: Drug-Company Payments Mirror Doctors’ Brand-Name Prescribing An excerpt:

“A ProPublica analysis has found that doctors who receive payments from the medical industry do indeed prescribe drugs differently on average than their colleagues who don’t. And the more money they receive, the more brand-name medications they tend to prescribe.

We matched records on payments from pharmaceutical and medical device makers in 2014 with corresponding data on doctors’ medication choices in Medicare’s prescription drug program.

Doctors who got money from drug and device makers prescribed a higher percentage of brand-name drugs overall than doctors who didn’t, our analysis showed. Even those who simply got meals from companies prescribed more brand-name drugs, on average.”

My take: Prescription patterns vary widely among physicians and often for good reason. At the same time, it is likely that in many cases variation in prescription patterns is influenced by frequent contact with pharmaceutical companies. As a consequence, this has the potential to make patients question whether their physician always has their best interest in mind and the potential to increase healthcare costs.

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