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.

Ondansetron for Irritable Bowel with Diarrhea?

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Briefly noted: A selected summary (Gastroenterol 2014; 147: 527-28) reviews the potential utility of ondansetron (median dose in adult participants was 4 mg) for irritable bowel syndrome with diarrhea (IBS-D) based on a recent study (Link to full online journal article: Randomized Trial of Ondansetron for IBS-D in Gut).

Several limitations are discussed including patient dropout, crossover study design, and short term study (in chronic disease).  As such, even though this study provides some evidence that ondansetron may be helpful for IBS-D, this probably needs “to be replicated in large-scale, parallel group, randomized, placebo-controlled trials…with longer duration of therapy..before the true place of ondansetron in the management of IBS-D is known.”

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Barrett’s Esophagus -New Review

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An up-to-date concise review: NEJM 2014; 371: 836-45.

A few key points:

  • “Despite the lack of high-quality evidence to support the practice, medical societies currently recommend endoscopic screening for Barrett’s esophagus in patients with chronic GERD symptoms who have at least one additional risk factor…such as age of 50 years or older, male sex, white race, hiatal hernia, elevated body-mass index…or tobacco use.”
  • If nondysplastic Barrett’s is identified, then followup endoscopy is recommended at intervals of 3 to 5 years.  Though, authors note that surveillance has not been proven to reduce death from esophageal cancer.
  • The authors recommend PPIs even in asymptomatic Barrett’s esophagus.

One other reference: Gastroenterol 2014; 147: 314-23.  “Statin Use is Assciated with a Decreased Risk of Barrett’s”

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Expert Recommendations for ARPKD

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A recent article (J Pediatr 2014; 165: 611-17) provides expert recommendations for the diagnosis and management of autosomal recessive polycystic kidney disease (ARPKD).

Some of the recommendations relevant to hepatologists:

  • Congenital hepatic fibrosis (CHF) “is presumed when portal HTN [hypertension] is present.”  Portal HTN is defined by splenomegaly (i.e.. spleen >2 cm below the left costal margin or >1 cm larger than ULN for age) and thrombocytopenia with a value of <150 mm3.  Other evidence of portal HTN includes varicose, ascites or hepatopulmonary syndrome.
  • “Liver biochemistries are not typically informative…one should monitor for associated neutropenia and thrombocytopenia.”
  • “Cholangitis may be difficult to diagnose definitively…should be considerd in any child with ARPKD with unexplained fever.” “Routine antibiotic prophylaxis is not indicated…antibiotic prophylaxis for 6-12 weeks after a cholangitis episode..may be considered.”
  • The “use of ursodeoxycholic acid as a choleric cannot be recommended.”
  • Hepatobiliary cancer is not a feature of ARPKD in children
  • “Limiting contact activities in individuals with a palpable spleen is highly controversial and not guided by evidence, but more by common sense.”
  • Recommends annual CBC, ultrasound at five years of age, and then follow-up ultrasound every 2-3 years.

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Do You Really Need Both a CRP and ESR?

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An erythrocyte sedimentation rate (ESR) and a C-reactive protein (CRP) are often ordered together, but many times provide similar information.  An ESR is a measure of acute phase proteins in the plasma.  A CRP is a proinflammatory acute phase reactant “which responds to infection and trauma by activating the complement/phagocytosis components of the immune system.”

Inevitably with the two tests, there is a higher sensitivity; for example, with osteomyelitis, one study found the paired testing had a 98% sensitivity compared with a 95% sensitivity for CRP alone (not statistically significant).  However, the authors note that “concordant or discordant results also have been found to lack clinical utility.”  As a consequence, the authors decided to investigate the costs of pairing these tests.  At their 739 tertiary care hospital, the additional cost resulted in charges between $250,000-400,000 more than ordering a single test.  They extrapolate the cost to $300 million nationally.

Take-home message: If you were spending your own money &/or trying to be a good steward of someone else’s, could you justify the expense of routinely obtaining both an ESR and a CRP?

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What physicians can learn from fast-food restaurants and …

Preventing Picky Eating Habits

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According to several studies in Pediatrics and summarized in NY Times, preventing picky eating habits and developing good diet habits relies on #1) introduction of fruits and vegetables in the first year of life and #2) avoid sugar-sweetened beverages in infancy.

NY Times Food Introduction Article

Here is an excerpt of the summary:

The package of 11 studies was published in the journal Pediatrics and was funded by the Centers for Disease Control and Prevention and the Food and Drug Administration, among others. Investigators tracked the diets of roughly 1,500 6-year-olds, comparing their eating patterns to those observed in a study that followed them until age 1…

As it turns out, “when infants had infrequent consumption of fruits and vegetables, they also had infrequent consumption at 6,” said Kelley Scanlon, an epidemiologist at the C.D.C. and the senior author of a few of the new studies.

Dr. Scanlon and her colleagues suggested that it is best to interest children in fruits and vegetables by late infancy — roughly between 10 and 12 months old.

Another study in the new series found that babies who consumed any amount of sugar-sweetened beverages were two times more likely to drink them at least once daily at age 6. A third study found that infants ages 10 to 12 months who were given sugar-sweetened beverages more than three times a week were twice as likely to be obese at age 6 than those who consumed none as infants.

Their analysis took into account factors that could skew results, like race, family income and breast-feeding. ..Breast-fed infants are more accepting of new foods than babies who drank the same-tasting formula day after day, research has shown. A C.D.C. study in the new series found that children who were breast-fed were more likely to consume water (versus sugar-sweetened beverages), fruits and vegetables at age 6.

Related blog post:

Sweetened Beverages -A Big Problem for Little Kids …

Reading Past the Headline: Low Fat vs Low Carb

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A recent study purportedly showed that a low-carb diet is superior to a low-fat diet.  However, David Katz explains how this study was flawed.  Here’s the link: Huffington Post “Low-fat” versus Low-carb and here’s an excerpt:

It was published in the Annals of Internal Medicine.. Allegedly, the researchers compared a low-fat to a low-carb diet. But in fact, they compared a diet that allowed up to 30 percent of calories from fat to a diet that allowed up to 40 grams of daily carbohydrate…

baseline carbohydrate intake was 240 grams per day, so while fat intake was “trimmed” 5 percent, carbohydrate intake in that assignment was slashed 75 percent. This might have been billed “a study to compare a really big change from baseline diet to a really small change from baseline diet.”…

the low-carb diet, since it was actually low-carb, obviously was much more restrictive than the low-fat diet, which wasn’t actually low-fat. That had the predictable result: those on the low-carb assignment took in many fewer calories…

I am not an advocate of low-fat diets. I think the concept is obsolete. I am an advocate, based on the evidence, of wholesome foods in sensible combinations. That dietary pattern can be low or high in fat, relatively lower or higher in carbohydrate.

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Accuracy of ENT diagnosis of Reflux Changes

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Many gastroenterologists suspiciously view a diagnosis of laryngopharyngeal reflux (LPR) as assessed by an Ear, Nose, and Throat (ENT or otorhinolaryngologist) physician.  This is due to a high degree of variability of these visible findings in a number of studies.  A recent pediatric study reaches the same conclusion (J Pediatr 2014; 165: 479-84).

In this study, the authors recruited 52 infants in an effort to establish a reflux finding score for infants (RFS-I).  This infant scale was modified based on a previous RFS developed in adults (Laryngoscope 2001; 111: 1313-7).  In these infants, scored videos were evaluated by 3 pediatric ENTs, 2 adult ENTs, and 2 gastroenterology fellows.

Specific finding:

  • “laryngeal erythema/edema showed the lowest observer agreement…it is often speculated that laryngeal edema is caused by LPR, but no convincing evidence is available to support this theory.”

Bottomline: “Only moderate interobserver agreement [of the RFS-I] was reached with a highly variable intraobserver agreement…the RFS-I and flexible laryngoscopy should not be used solely to clinically assess LPR related findings of the larynx, nor to guide treatment.”

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If a Guideline Falls in The Woods, and No One Hears It

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Two recent articles highlight how ineffective guidelines can be:

  • J Pediatr 2014; 165: 570-6.
  • J Pediatr 2014; 165: 585-91.

In the first retrospective multicenter study, the authors note that hospitals with institutional clinical practice guidelines (CPGs) for bronchiolitis did not have significant reductions in the use of tests and treatments (eg. complete blood count, chest X-ray, bronchodilator use, steroid and antibiotic use).  However, two factors, time that CPG had been in place and ready access to an online written document were associated with a reduction in tests and corticosteroids.

In the second study, a retrospective cohort study of 17,299 cases of uncomplicated pneumonia at 125 hospitals, antibiotic choices rarely coincided with recommended guidelines.  “Ampicillin or penicillin G is strongly recommended for first-line management of uncomplicated pediatric CAP [community acquired pneumonia] in the inpatient setting barring substantial high level penicillin resistance of Streptococcus pneumoniae in the community.” Yet, in this study, about 75% received a third-generation cephalosporin and 5-10% received monotherapy with a macrolide.  The former is generally unnecessary and not advantageous, whereas the latter has a lower efficacy. Less than 1% received a recommended choice.

Bottomline: These studies have obvious implications well beyond bronchiolitis and pneumonia. Experts can agree on plethora of guidelines but they are almost meaningless without efforts to get clinicians to use them.

Reducing Diagnostic Uncertainty in Hirschsprung’s Disease

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Previously this blog noted the emergence of calretinin immunohistochemisty (What is calretinin? | gutsandgrowth).  Now, more data has been published indicating that calretinin reduces inconclusive rectal biopsies for the diagnosis of Hirschsprung’s disease (JPGN 2014; 58: 603-07).

The authors analyzed data retrospectively for 45 patients prior to the use of calretinin and 42 patients after calretinin introduction.

Key finding: 37.8% (17 of 45) of patients had inconclusive rectal biopsies prior to use of calretinin compared with 11.9% (5 of 42) after including calretinin immunohistochemistry.