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.

Overlooking Obesity in Hospitalized Children

Posted on November 24, 2015 by gutsandgrowth

A recent study (MA King et al. J Pediatr 2015; 167: 816-20) shows that physicians and physician trainees rarely addressed overweight/obesity in hospitalized children at a Utah pediatric hospital.

Using a chart review and an administrative database, the authors note that overweight/obesity was identified in 8.3% (n=25) and addressed in 4% (n=12) of 300 hospitalized children with overweight/obesity. They conclude that “this represents a missed opportunity for both patient care and physician trainee education.”

My take: In many cases, addressing overweight/obesity at a stressful time like a hospitalization may be unwelcome. In children who are not very sick, offering nutritional counseling would be worthwhile. For others, I think encouraging outpatient followup would be reasonable.

Also noted: “High Prevalence of Nonalcoholic Fatty Liver Disease in Adolescents Undergoing Bariatric Surgery” SA Xanthakos et al. Gastroenterol 2015; 149: 623-34. In this cohort of 242 adolescents, 59% had NAFLD. None had cirrhosis; stage 3 fibrosis was identified in 0.7%. Comment: I’m surprised that only 59% had NAFLD.

So, What Could Go Wrong with Unregulated Dietary Supplements?

Posted on November 23, 2015 by gutsandgrowth

As noted before on this blog (see below), dietary supplements, marketed as health aids, can be quite dangerous. More data on the complications has been published (AI Geller et. NEJM 2015; 373:1531-1540).

Here is an excerpt of a summary from the NY Times: Dietary Supplements Lead to 20,000 E.R. Visits Yearly, Study Finds

A large new study by the federal government found that injuries caused by dietary supplements lead to more than 20,000 emergency room visits a year, many involving young adults with cardiovascular problems after taking supplements marketed for weight loss and energy enhancement.

The study is the first to document the extent of severe injuries and hospitalizations tied to dietary supplements, a rapidly growing $32 billion a year industry that has attracted increased scrutiny in the past year and prompted calls for tougher regulation of herbal products….

Among the injuries cited were severe allergic reactions, heart trouble, nausea and vomiting, which were tied to a broad variety of supplements including herbal pills, amino acids, vitamins and minerals. Roughly 10 percent, or about 2,150 cases yearly, were serious enough to require hospitalization, the researchers found…

More than a quarter of the emergency room visits occurred among people ages 20 to 34, and half of these cases were caused by a supplement that was marketed for weight loss or energy enhancement…

Medical experts say that these products can be particularly hazardous because they have potent effects on the body and are frequently adulterated with toxic chemicals. The new study found that cardiovascular problems were even more commonly associated with weight loss and energy supplements than prescription stimulants like amphetamine and Adderall, which by law must carry warnings about their potential to cause cardiac side effects…

Under a 1994 federal law that has been widely criticized by health authorities, supplements are considered safe until proved otherwise.

Other points from the study:

“Child-resistant packaging is not required for dietary supplements other than those containing iron”
While these supplements result in <5% of the numbers for hospitalizations and admissions for pharmaceutical products, “dietary supplements are not regulated and marketed under the presumption of safety.”

Related blog posts:

The Latest on Lynch Syndrome

Posted on November 22, 2015 by gutsandgrowth

Briefly Noted:

AGA Guidelines on Diagnosis and Management of Lynch Syndrome: JH Rubenstein et al. Gastroenterol 2015; 149: 777-82. Technical Review 783-813. Patient Guideline Summary 814-14.

MB Yurgelun et al. Gastroenterol 2015; 149: 604-13. Multigene panel testing from 1260 individuals with clinical Lynch syndrome. 9% had Lynch syndrome mutations identified, 5.6% had other cancer predisposing genes (eg. BRCA1) identified, and 479 had variants of uncertain clinical significance.

Related blog post:

Updated Guidelines on Genetic Testing/Management for …
Atlanta Botanical Garden, Bruce Munro Exhibit

IBD ‘Pearls’

Posted on November 21, 2015 by gutsandgrowth

A clinical pearl is “a short, straightforward piece of clinical advice.” Here are a few:

2015 DDW abstract –#536 DR Hoekman et al “Non-trough IFX concentrations reliably predict trough levels and accelerate dose-adjustment in Crohn’s disease.” This abstract examined data from 20 CD patients. The authors noted that infliximab concentrations of 15 mcg/mL or higher at week 4 and 7.5 mcg/mL or higher at week 6 appeared to predict trough concentrations of 3 mcg/mL or higher at week 8.

U Kopylov et al. Inflamm Bowel Dis 2015; 21: 1847-53. This nested case control study identified 19,582 eligible patients. Key findings:

Treatment with thiopurines for more than 5 years did not increase the risk of lymphoma, melanoma or colorectal cancer.
There was an association between thiopurine use and nonmelanoma skin cancer (OR 1.78).
No association was found between the risk of the evaluated malignancies and anti-TNFα medications

K Huth et al. Inflamm Bowel Dis 2015; 21: 1761-68. This prospective cohort study completed over 2 successive influenza seasons showed that offering education and access to vaccination improved rates of vaccination from 47% (2011-12) to 75% (2013-14). The education module is available: www.cheo.on.ca/en/IBDflu

KH Katsanos et al. “Review article: non-malignant oral manifestations in inflammatory bowel disease” Aliment Pharmacol There 2015; 42: 40-60. (Thanks to Ben Gold for this reference). This review article provides extensive information about oral lesions in IBD, differential diagnosis, numerous pictures, and management recommendations. Some oral lesions are directly related to IBD, others can be induced by vitamin deficiencies or by medications.

One of my pet peeves -I avoid using straws. I heard this statistic several years ago and also see too many littered straws.

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.

Rectal Suction Biopsies Less Accurate in Infants <40 days

Posted on November 20, 2015 by gutsandgrowth

Briefly noted:

RJ Meinds et al Clin Gastroenterol Hepatol 2015; 13: 1801-07. In this retrospective analysis (1975-2011) of 529 rectal suction biopsies (RSBs) from 441 patients, the authors note lower sensitivity for RSB in infants <40 days.

From Table 3:

Hirschsprung’s disease patients <40 days: true-positive RSB 56/111 (50%), inconclusive RSB 32/111 (29%) and false negative 23/111 (21%)
Hirschsprung’s disease patients >40 days: true-positive RSB 136/154 (88%), inconclusive RSB 14/154 (9%) and false negative 4/154 (3%)
Non-HD patients <40 days: inconclusive RSB 2/48 (4%), false-positive RSB 0/48 (0%)
Non-HD patients >40 days: inconclusive RSB 10/216 (5%), false-positive RSB 1/216 (<1%)

Bottomline: This study may need to be replicated due to improvements in biopsy analysis (eg. calretinin); however, in the first 40 days of life, RSBs are more often inconclusive and/or false-negatives. The use of anorectal manometry may be helpful.

Related blog posts:

The Problem with Black Box Warnings

Posted on November 19, 2015 by gutsandgrowth

A short article (T Elraiyah, et al. Ann Intern Med. Published online 29 September 2015 doi:10.7326/M15-1097) explains the problem with current black box warnings and what can be done to improve them. “A black box warning (BBW) is the highest level of warning issued by the U.S. Food and Drug Administration (FDA)…These warnings are required when there is reasonable evidence of association between the drug and a significant safety concern.” Key points:

BBWs “have been the subject of controversy, due in part to their opaque connection to the underlying body of evidence.”
The authors reviewed 70 BBWs from the top 200 drugs. “We found only 19 (27%) provided an estimate of the likelihood of harm, and only 8 (11%) reported a CI for that estimate.”
“Fewer than half (43%) presented the source of evidence. None described the quality (certainty of the evidence).”
“None provided guidance on how to communicate or act on the evidence.”

The authors state that “BBWs infrequently contain 3 elements required for evidence-based practice (estimate of effect, source and trustworthiness of evidence, and guidance on implementation).” There are some medicines that already have a well-presented BBW, including Advair-diskus.

My take: Black box warnings can generate a lot of anxiety and may adversely affect the calculation of benefit versus harm. Improving them could be helpful for patients and doctors alike.

Related blog posts:

Atlanta Botanical Gardens

HCV Guidelines

Posted on November 18, 2015 by gutsandgrowth

The AASLD-IDSA Recommendations for Hepatitis C Virus have been published (Hepatology 2015; 62: 932-954). The entire report is accessible from hcvguidelines.org and from the link: HCV Guidance 2015. While having a hard copy is easy to work with, the HCVguidelines website is likely to remain more up-to-date.

A few recommendations to highlight:

#6. “Antiviral treatment is recommended for all patients with chronic HCV infection, except those with limited life expectancy due to nonhepatic causes (I-A)
#7. “If resources limit the ability to treat all infected patients immediately as recommended, then it is most appropriate to treat those at greatest risk of disease complications” (see Tables 3 and 4)
#8. “Use of noninvasive testing or liver biopsy is recommended in order to assess the degree of hepatic fibrosis and, hence, the urgency of immediate treatment. (I-A)”

Other Hepatology studies of interest, briefly noted:

Hepatology 2015; 62: 684-93. Nucleos(t)ide analog “treatment does not increase the risk of renal and bone events in general. Nucleotide analogs may increase the risk of hip fractures, but the overall event rate is low.” This study examined 46,454 untreated chronic hepatitis B patients in comparison to 7,046 treated patients.

Hepatology 2015; 62: 715-25. This study looked at the safety of simeprevir and sofosbuvir in hepatitis C-infected patients. “Adverse safety outcomes were similar to matched untreated controls, suggesting that safety events reflect the natural history of cirrhosis and are not related to treatment.”

Hepatology 2015; 62: 773-83. This study found that “NAFLD is independently associated with subclinical myocardial remodeling and dysfunction.”

Bruce Munro, Atlanta Botanical Gardens

Nutrition Symposium Georgia AAP (Part 3)

Posted on November 17, 2015 by gutsandgrowth

Along with Kylia Crane, I presented the final lecture at this year’s Georgia AAP Nutrition Symposium: Optimizing Nutrition and Formula Selection in Toddler’s and Children. Kylia is a nutritionist and dietician at the Georgia AAP who works on a multitude of projects to enhance nutrition for pediatric patients across the state. This lecture was intended as a practical review of feeding problems and poor growth.

After a brief discussion of some basic feeding principles, the lecture focused on specific case presentations and then reviewed formula selection. At the end, I quickly mentioned some of the big nutrition stories for 2015. The entire talk will be available at the Nutrition4Kids website.

Here are some of the slides:

Additional resources that I discussed:

FeedingTubeAwareness.com

Ellyn Satter:

“Child of Mine”
“The Secrets of Feeding a Healthy Family”

Laura Jana/Jennifer Shu:

“Food Fights”

In the lecture, I credited some of the material to Dr. Praveen Goday who shared his slides from a previous lecture. In addition, I am grateful to Dr. Seth Marcus who provided input into the lecture content.

Related blog posts:

Nutrition Symposium Georgia AAP (Part 2)

Posted on November 16, 2015 by gutsandgrowth

Last week I summarized an excellent talk by Ronald Kleinman. For me, I had never heard such a concise and definitive rebuttal of the claims of those fearful of food biotechnology. There were three other lectures at the symposium. These three lectures covered areas that are well-known to pediatric gastroenterologists but less familiar to general pediatricians. The full set of slides are available at the Georgia AAP Symposium Website.

Jeff Lewis had an excellent lecture that tied together gluten and our microbiome: Gluten – Eat not, suffer not and Microbiome 101: Waste Not, Want Not

After reviewing celiac disease and other wheat-related disorders (eg. wheat intolerance syndrome, and wheat allergy), he summarized a great deal of information regarding the human microbiome and which factors influence this. In addition, he had the opportunity to briefly present data from his research on fecal microbiota transplantation (for C diff) and its influence on the microbiome over time. Here are a couple of slides from his talk:

Key points:

“It is hard to communicate science to families. It is a huge challenge for us.”
Dermatitis herpetiformis (rare in kids), a rash associated with celiac disease, can be treated with Dapsone. This rash has caused such severe itching that there are cases of suicide that have been reported.
For celiac disease, Dr. Lewis recommends testing of 1^st degree relatives but this needs to be after gluten exposure and before gluten-free diet.
Wheat allergy reviewed. Skin test positivity does not prove that you are allergic to food. IgG based testing is worthless –it means you have been exposed to a food, but is not an indication of food allergy.
Nonceliac gluten sensitivity (aka. wheat intolerance syndrome): need to test for celiac first. No tests/biomarker that can confirm this diagnostic. This appears to be a true disease; there is a small subset of patients who develop symptoms with a double-blind challenge.
Microbiome –more bacterial DNA in us than human DNA. New organisms –archaea kingdom. Now a specimen of a person’s microbiome can be run for <$50.
Microbiome terms: Richness, Diversity, and Dysbiosis. Many diseases are associated with dysbiosis (obesity, IBD), but there is a ‘chicken and the egg’ problem. Is dysbiosis a causal factor or a secondary factor?
Xyloglucans (in lettuce) –not broken down by humans and affected by gut bacteria.
Mice given stool from fat mice or fat person become heavy.

Nutrition Symposium Georgia AAP (Part 1)

Posted on November 15, 2015 by gutsandgrowth

At this year’s nutrition symposium, Dr. Stan Cohen presented the latest information on nutrition and inflammatory bowel disease. His entire presentation will be on the Nutrition4Kids website. While I took a few pictures, my notes from his presentation were minimal, mainly because I had to give a talk afterwards. He reviewed how the microbiome can be influenced by diet and that this in turn can result in phenotypic changes. Specific complications from poor diet/nutrient deficiencies were discussed. In addition, data from exclusive enteral nutrition and the specific carbohydrate diet were presented. Here are some slides from his lecture (also available at Georgia AAP Symposium Website):

Related blog posts: