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.

Business of Blood in Decline

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With refinements in surgery, including minimally invasive techniques, and studies showing that transfusions are not needed in many conditions until patients have bigger drops in their hemoglobin, there has been a big drop in the need for blood transfusions.  I was unaware of how much of a drop until I read this article from the NY Times: Blood Industry Shrinks

An excerpt:

Changes in medicine have eliminated the need for millions of blood transfusions, which is good news for patients getting procedures like coronary bypasses and other procedures that once required a lot of blood.

But the trend is wreaking havoc in the blood bank business, forcing a wave of mergers and job cutbacks unlike anything the industry, which became large scale after World War II, has ever seen.

Transfusions are down almost one-third over the last five years, to about 11 million units last year from about 15 million units, according to the American Red Cross, which has about 40 percent of the market. With “minimally invasive” techniques like laparoscopic surgery and other shifts in medicine, demand for blood continues to drop despite population growth and a soaring number of people over 65, who have the most surgeries requiring blood.

Blood bank revenue is falling, and the decline may reach $1.5 billion a year this year from a high of $5 billion in 2008.

Other useful points included the following:

  • The decline in demand is opportune given the growing list of exclusions
  • Red blood cells have a shelf life of 42 days; platelets 5 days
  • While blood is donated, hospitals pay $225-240 per unit and patient may be charged ~$1000 per unit.  Hospitals have been trying to lower their costs given the changes in supply and demand.

Related blog post:

Transfusion strategy in acute GI bleeding | gutsandgrowth

Understanding the Costs and Benefits of HCV Treatment

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A useful editorial in JAMA (available free online –) provides a useful overview of HCV treatments in terms of costs and strategies for using new therapies.

A couple of useful points

  • Given the cost of medications, many are using the newer therapies in those who absolutely need treatment now and waiting for costs to improve in others
  • “The ultimate approach to cost will be lower prices, which will occur as more products create competition.”
  • “This fall, an oral combination of sofosbuvir and ledipasvir will be introduced that inhibits both the NS5B polymerase and NS5A polymerase and has been shown to reduce treatment to an 8-week course with cure rates of more than 95%.2 Now, a chronic disease that affects millions of Americans can be cured by well-tolerated oral medications.”
  • Because of the large number of potential patients, “the simple math is that treatment of patients with HCV could add $200 to $300 per year to every insured American’s health insurance premium for each of the next 5 years.”

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Safety Signal for Anti-TNFs

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In a large population of inflammatory bowel disease patients, anti-tumor necrosis factor medications (anti-TNFs) did not increase the risk of cancer in a recent study from Denmark.  This link provides a summary of the study (JAMA 2014 June 17 [doi:10.1001/jama.2014.5613]) in GI & Hepatology News: Anti-TNFs -Safety Signal

Here’s an excerpt:

This study “assessed the risks of any cancer and 11 individual cancers, including malignant melanoma, in 56,146 IBD patients aged 15 and older…during 1999-2012, of whom 4,553 took TNF-alpha antagonists.  Median follow-up was 9.3 years…A total of 6.7% of the patients who never took TNF-alpha antagonists developed cancer during follow-up compared with 1.8% of patients who took the drugs…

Stratifying for cancer risk according to years since first exposure, no specific time-dependent pattern was observed in our study…an increased risk in the long term cannot be excluded.”

In another systemic review study (Clinical Gastroenterology and Hepatology Volume 12, Issue 9, Pages 1443–1451, September 2014) focused on pediatric IBD patients (n=5528), the authors found that “Two patients developed lymphoma (2.1/10,000 PYF). This value was … lower than the population of pediatric patients receiving thiopurine monotherapy (4.5/10,000 PYF; SIR, 0.47; 95% CI, 0.03–6.44)”…”the risk of lymphoma was no greater among children with IBD who received anti-TNF therapy than those treated with other IBD therapies or adults treated with anti-TNF agents. The rate of serious infection was significantly lower among pediatric patients with IBD treated with anti-TNF agents than those treated with steroids, or adults with IBD who received anti-TNF therapy.”  Here’s the link: anti-TNF therapy with lower lymphoma risk than thiopurines in pediatrics

How Proton Pump Inhibitors Can Cause Infections

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In yesterday’s blog, the editorial on “Acid-reducing agents in infants and children: friend or foe?” also commented on an additional study (JAMA Pediatr. 2014. doi: 10.1001/jamapediatrics.2014.696) which addresses the issue of how proton pump inhibitors (PPIs) may contribute to an increased risk of infections.  It is well-known that use of PPIs (and to a lesser extent histamine-2 receptor antagonists) contribute to a significant increased risk of community-acquired pneumonias and gastrointestinal infections (probably including necrotizing enterocolitis in infants).

In this study, (from the editorial) “acid suppression was associated with a positive gastric culture (P =.003) and increased median concentration of gastric bacteria (P<.001). Full-column nonacid reflux was associated with higher concentrations of bacteria in the lung.”

In this era of pioneering microbiome research, it is not surprising that chronic changes in gastric acid production could cause these results.  This is something to consider when calculating risks and benefits, particularly in situations where the benefits are quite minimal.

Here’s the abstract:

Importance  The use of acid suppression has been associated with an increased risk of upper and lower respiratory tract infections in the outpatient setting but the mechanism behind this increased risk is unknown. We hypothesize that this infection risk results from gastric bacterial overgrowth with subsequent seeding of the lungs.

Objectives  To determine if acid-suppression use results in gastric bacterial overgrowth, if there are changes in lung microflora associated with the use of acid suppression, and if changes in lung microflora are related to full-column nonacid gastroesophageal reflux.

Design, Setting, and Participants  A 5-year prospective cohort study at a tertiary care center where children ages 1 to 18 years were undergoing bronchoscopy and endoscopy for the evaluation of chronic cough. Acid-suppression use was assessed through questionnaires with confirmation using an electronic medical record review.

Main Outcomes and Measures  Our primary outcome was to compare differences in concentration and prevalence of gastric and lung bacteria between patients who were and were not receiving acid-suppression therapy. We compared medians using the Wilcoxon signed rank test and determined prevalence ratios using asymptotic standard errors and 95% confidence intervals. We determined correlations between continuous variables using Pearson correlation coefficients and compared categorical variables using the Fisher exact test.

Results  Forty-six percent of patients taking acid-suppression medication had gastric bacterial growth compared with 18% of untreated patients (P = .003). Staphylococcus (prevalence ratio, 12.75 [95% CI, 1.72-94.36]), Streptococcus (prevalence ratio, 6.91 [95% CI, 1.64-29.02]), Veillonella (prevalence ratio, 9.56 [95% CI, 1.26-72.67]), Dermabacter (prevalence ratio, 4.78 [95% CI, 1.09-21.02]), and Rothia (prevalence ratio, 6.38 [95% CI, 1.50-27.02]) were found more commonly in the gastric fluid of treated patients. The median bacterial concentration was higher in treated patients than in untreated patients (P = .001). There was no difference in the prevalence (P > .23) of different bacterial genera or the median concentration of total bacteria (P = .85) in the lungs between treated and untreated patients. There were significant positive correlations between proximal nonacid reflux burden and lung concentrations of Bacillus (r = 0.47, P = .005), Dermabacter (r = 0.37, P = .008), Lactobacillus (r = 0.45, P = .001), Peptostreptococcus (r = 0.37,P = .008), and Capnocytophagia (r = 0.37, P = .008).

Conclusions and Relevance  Acid-suppression use results in gastric bacterial overgrowth of genera including Staphylococcus and Streptococcus. Full-column nonacid reflux is associated with greater concentrations of bacteria in the lung. Additional studies are needed to determine if acid suppression–related microflora changes predict clinical infection risk; these results suggest that acid suppression use may need to be limited in patients at risk for infections.

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GERD Treatment in Infants: “Friend or Foe”

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From a recent JAMA Peds editorial: (JAMA Pediatr. Published online August 18, 2014. doi:10.1001/jamapediatrics.2014.1263)

An excerpt:

Gastroesophageal reflux disease (GERD) is common in infants and children and has been estimated to affect as much as 3.3% of the pediatric population.1 Despite this, we still struggle with the management of GERD. With a growing body of literature that illustrates a lack of efficacy and alarming adverse effects, there is increasing reason to limit the empirical use of acid suppression therapy in children.

Other points highlighted in this editorial:

  • 36% of pediatricians prescribe PPIs for infants with uncomplicated regurgitation -“despite evidence and recommendations against this approach.”
  • 39% of pediatricians prescribed proton pump inhibitors (PPIs) for infants with unexplained crying
  • Conditions predisposing a child for severe GERD include those with neurological impairment, repaired esophageal atresia, cystic fibrosis, hiatal hernia, repaired achalasia, and lung transplantation.
  • In the related article ((JAMA Pediatr. doi: 10.10001/jamapediatrics.2014.1273), the authors reviewed 8 studies of histamine-2 receptor antagonists (H2RAs) and noted no improvement in overall symptoms infants.  In older age groups, H2RAs were more effective than placebo in symptom reduction, and histological healing.

Take-home message: “It is becoming clearer that in many circumstances, prescribing acid-reducing medication to infants is doing no good and increasing the risk of harm.”

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“Bacterial Penetration Cycle Hypothesis”

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Initially, this blog was titled: “Even More Work for Our IBD Nutritionists?”  If you get to the bottom of this post, you will know why.

A provocative study (Inflamm Bowel Dis 2014; 20: 1353-60) describes the use of partial enteral nutrition (PEN) as effective for induction of remission in children and young adults with Crohn’s disease (CD).  I’m a little wary commenting on this study as many individuals may take a glimmer of information and subject themselves to empiric trials.  In fact, a recent case report (N Engl J Med 2014; 371:668-675) described an adult who without medical advice used fecal transplant therapy (obtained from spouse and infant) to self-treat his ulcerative colitis.  In the case report, this patient ultimately was diagnosed with a secondary cytomegalovirus (CMV) infection and the fecal transplant was not effective.

With regard to the PEN study, the authors treated 47 patients (34 children) with up to 50% of their diet as a polymeric formula (Modulen or Pediasure) along with dietary counseling/changes.  The authors note that CD “may arise from a sequence of events involving changes in the microbiome, intestinal permeability leading to bacterial adherence or penetration of the epithelium, and subsequent stimulation of the adaptive immune response leading to tissue damage.  We have termed this sequence the Bacterial Penetration Cycle Hypothesis.”  Given the compelling improvements noted with exclusive enteral nutrition (EEN), the authors sought to modify the diet after an initial clinical response in two patients who could not adhere to EEN.

Design: Strict diet for 6 weeks with 50% of calories from formula, then less restricted diet for next 6 weeks (25% of calories from formula).  Also, diet required exclusion of gluten, dairy, animal fat, processed meats, products containing emulsifiers, candies, chocolates, gum, packaged snacks, sauces, and canned goods.  A more extensive listing of the foods is given in the appendix (page 1360).  The authors measured the clinical response with PCDAI, Harvey Bradshaw index, and bloodwork (eg. CRP, ESR, albumin, and hemoglobin).

Key finding:

  • 33 (70.2%) achieved a remission on this PEN diet; 78.7% (n=37) had a clinical response.
  • Normalization of CRP occurred in 21 of 30 patients (70%) of those with a clinical remission.

Take home message: A PEN diet needs more study.  I would not advise someone to radically change their diet without the instruction of a qualified nutritionist, unless the individual wants to be another case report of something gone awry.

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Hepatology Update (Part 2) -Summer 2014

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Hepatology 2014; 60: 715-33.  This publication is the AASLD Practice Guideline for Hepatic Encephalopathy in Chronic Liver Disease.  The recommendations are too extensive to summarize.  Here’s one: despite concerns about efficacy, “lactulose is the first choice for treatment of episodic” overt hepatic encephalopathy.  Rifaximin is an effective add-on therapy to lactulose for prevention of OHE recurrence. AASLD Guidelines Website

Hepatology 2014; 60: 679-86. Using the Drug-Induced Liver Injury Network between 2004-2012, the authors identified 22 cases of hepatotoxicity attributed to statins.  Median age was 60 years.  The latency to onset of symptoms varied from 34 days to 10 years with a median of 155 days. Nine patients had a cholestatic hepatitis pattern and 12 had hepatocellular injury, including six with an autoimmune phenotype. Severity: nine required hospitalization, four had evidence of hepatic failure and one died.

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Desperate for a Kidney Transplant

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A recent NY Times article delves into the issues of kidney trafficking: NY Times Kidney Trafficking

Here’s an excerpt:

In the United States, the number of kidney transplants has remained static for a decade at 16,000 to 17,000 a year. During the same period, the waiting list for kidneys from deceased donors has nearly doubled, passing 100,000 this year. The median wait time for an adult [for a kidney transplant] is more than four years, and more than 4,000 die waiting each year.

Some physicians and ethicists question the relative morality of allowing thousands to die just because the means of saving them is considered repugnant. A regulated marketplace, they say, could all but eliminate the shortage. It is no accident, they argue, that the only country that allows compensation for donors — Iran — effectively has no waiting list.

Experts list China, Egypt, India, Pakistan, Sri Lanka, Turkey, Eastern Europe and the former Soviet republics as hot spots for organ trafficking. But illicit transplants usually go undetected unless there is a surgical mistake or a payment dispute. Prosecutions are thwarted by false affidavits, toothless laws and lack of international cooperation, particularly regarding extradition.

Hepatology Update -Summer 2014

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Preventing Perinatal Transmission of Hepatitis B Virus (HBV): Hepatology 2014; 60: 468-76.  This nonrandomized study, conducted between 2009-2011 with approximately 700 patients, showed that the rate of perinatal transmission of can be brought down almost to zero by instituting therapy with either telbivudine or lamivudine in the third trimester of pregnancy.  The accompanying editorial (pgs 448-51) indicates that either telbivudine or tenofovir (both pregnancy class B agents with regard to teratogenicity) are preferred agents due to higher barrier to resistance. And, the article suggests starting as early as week 28 (especially if high viral HBV DNA load) and no later than 32 weeks gestation. Other recommendations from editorial include stopping antiviral after delivery in women who intend to breastfeed.

More on coffee: Hepatology 2014; 60: 661-69.  Coffee but not tea conferred protection from cirrhosis mortality.  “Compared to non-daily coffee drinkers, those who drank two or more cups per day had a 66% reduction in mortality risk.”  This study also had an accompanying editorial (pg 464-67) which reviews the biologic plausibility and potential mechanisms.

NASH pathology: Hepatology 2014; 60: 565-75.  The study describes a more precise way to categorize the diagnosis of nonalcoholic steatohepatitis (NASH) using the European Fatty Liver Inhibition of Progression (FLIP) pathology consortium proposal.  The diagnosis of NASH requires the presence of ballooning and lobular inflammation in addition to steatosis.  Using the FLIP approach, diagnosis concordance increased significantly.

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