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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.

NASPGHAN Preview

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I had a few free minutes so I decided to take a look at a bunch of upcoming lectures from the 2013 NASPGHAN upcoming meeting.  With electronic media, it is easy to take a quick glance.  Here’s the master link to all of the following talks:

Annual Meeting page.

Some of the power point lectures that I’ve seen so far:

  • Is my PPI dangerous for me? Eric Hassall MBChB, University of British Columbia One point in his slides that I had not seen much about was a hypothesis that PPI use may predispose to the development of eosinophilic esophagitis by allowing food proteins to be more intact ( attributed to Merwat, Spechler. Am J Gastro ’09).  He explains that “acid reflux” is a clever marketing term and has a slide with Madmen actors.  If there is “acid,” one must need acid suppression.
  • My child doesn’t go to school Lynne Walker MD, Vanderbilt University.  Lynne shows an interesting fax from a parent that asks if the problem is physical, how will she help? And, if it is psychological, how can this be remedied?  She outlines a lot of pain theory and indicates that parents need to become health coaches, avoid catastrophizing (?spelling), and encourages mental health evaluation.  Use the parents words ‘I’m going to refer xxx for relaxation and stress management.’
  • My child’s H. pylori will not go away – (the resistant bug) Benjamin Gold MD, Children’s Center for Digestive Healthcare. Ben manages to stuff so much information into his talk.  His talk is like one of those clown cars where more and more people keep coming out.  He has slides with worldwide resistance maps, slides with treatment regimens and algorithms, and the reasons for treatment failure. Perhaps I can convince him to give a live preview.
  • Administrative/executive functioning Richard Colletti MD, Fletcher Allen Healthcare. Offers personal and pragmatic advice for career advancement.  His slides indicate that he started his GI fellowship at age 40.  One of his quotes, “80% of success is showing up” (Woody Allen) is definitely true.  It’s pretty much akin to what I learned about success in medical school.  You need the three As: availability, affability, and ability.  My mentor said the first was what people needed most.
  • The changing face of intestinal transplantation
    Simon Horslen MD, Seattle Children’s Hospital.  Lecture notes that number of intestinal transplants have decreased dramatically, particularly in children. In 2012, only about 100 intestinal transplants were performed whereas it had peaked at nearly 200.  Much of the credit is due to intestinal rehabilitation work and adjustments in parenteral nutrition (eg. lipid minimization, line care).  Two most common reasons for intestinal transplantation at this time are gastroschisis and volvulus.
  •  Gluten sensitivity: Fact or fiction Alessio Fasano MD, MassGeneral Hospital for Children. This blog has covered a lot of the same material, but Alessio’s slides are pretty impressive.  Also, I was not aware that Lady Gaga consumes a gluten-free diet
  • Controversies in parenteral nutrition Christopher Duggan MD, Boston Children’s Hospital.  This lecture provides a timely update on nutrient deficiencies due to component shortages and discusses lipid minimization compared with fish oil-based lipid emulsions.
  • Vitamin D and immunity James Heubi MD, Cincinnati Children’s Hospital and Medical Center.  In the beginning of the slides, Jim provides a very user-friendly definition of an expert and a suitable picture.  He indicates that in 2011 there were 3746 vitamin D publications but inexplicably only chooses to review a tiny fraction.

At the time of this posting, I haven’t had a chance to look through these talks:

 

 

How long does it take the liver to recover from PNALD?

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It takes a long time, even when there is no longer biochemical evidence of parenteral nutrition-associated liver disease (PNALD).  A recent study provides long-term data from a population-based, cross-sectional study on liver histology from pediatric intestinal failure (IF) patients (Hepatology 2013; 58: 729-38).  Patients were followed from 1984-2010.  IF was defined as having either >50% small bowel resection or need for PN >30 days.

The 38 IF participants had a median age of 7.2 years.  16 remained on PN after 74 months (range  2.5-204), 22 had weaned off PN 8.8 years (range 0.3-27) earlier after an average of 35 months of PN exposure.

Key findings:

  • Abnormal liver histology was present in 94% of patients on PN and 77% off PN.
  • Nearly 60% of patients on long-term PN had significant or severe fibrosis (Metavir stage ≥2).
  • Significant liver fibrosis and steatosis persisted after weaning off PN. That is, “liver histology remains abnormal up to 9 years after weaning off PN in the majority of IF patients.”
  • One patient off PN developed esophageal varices.
  • Risk factors for increased fibrosis: extensive small intestinal resection, (P=.002) loss of ileocecal valve (P=.048), and recurrent sepsis (P=.002).

Bottomline: While there have been important clinical advances in the management of IF, the data from this study indicate that many patients who have normal liver biochemistries continue to have abnormal liver histology.  Whether this will have an important clinical impact is not known.

Previous related blog entries:

Pediatric Consensus Statement: Perianal Crohn Disease

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A recent report provides a useful reference for the often difficult care of pediatric perianal Crohn disease (JPGN 2013; 57: 401-412).

The statement reviews the background, etiology, presentation and classification systems. Most helpful are Figures 2 & 3.

Figure 2 provides an algorithm for assessment and treatment of perianal fistula.

  1. History/Physical (including rectal exam for stricture) along with colonoscopy
  2. Next either exam under anesthesia (with or without endoscopic ultrasound) or MRI
  3. Main treatments:
  • consider antibiotics, anti-TNF, and immunomodulators
  • in some cases a noncutting seton or fistulotomy will be needed
  • consider advancement flap in rectovaginal fistulae

Figure 3 provides an algorithm for assessment and treatment of perianal abscess.

  1. History/Physical (including rectal exam for stricture) along with colonoscopy
  2. Next either exam under anesthesia (with or without endoscopic ultrasound) or MRI
  3. Main treatments:
  • Incision and drainage
  • Noncutting seton if perianal fistula
  • Antibiotics
  • Treatment of intestinal disease

After outlining these algorithms, the report details the treatments.  Almost all treatments that are effective or questionable for Crohn’s disease are discussed.  The report reiterates that ‘corticosteroids must be used with caution in treatment of perianal fistula; studies have shown worse fistula outcomes for steroid-treated patients.

With regard to noncutting setons, the authors note that they do not prevent treatment with biologic agents and help prevent abscess formation.  They “usually deteriorate and fall out on their own in about 1 year.”  Medical therapy often allows for seton removal.

Ostomy diversion can be helpful in patients with severe perianal disease; however, “the risk of the ostomy becoming permanent is significant.”

Rectal strictures are typically dilated with multiple sessions with general anesthesia.  The goal is at least 18 mm in younger patients and at least 24 mm in adolescents.

Related blog post:

Previous references:

  • -Clin Gastro & Hep 2010; 8: 13.  Another algorithm.  For simple fistula, Rx w abx & medical (thiopurine or Remicade).  If not better, fistulotomy, &/or Rx as complex fistula.  For complex fistula, seton placement, abx, anti-TNF.  If not better, consider tacrolimus or proctectomy.
  • -JPGN 2010; 50: 99.  Perianal dz in young children may be due to autoimmune neutropenia.
  • -Clin Gastro & Hep 2009; 7: 1037.  MRI study of choice for perianal fistulas.  Algorithm: If superficial fistula, Rx c fistulotomy & Abx If deeper, noncutting seton c Abx, 6-MP +/- infliximab; if not effective, try tacrolimus; if not effective, surgery
  • -Ann Intern Med 2001; 135: 906-918.
  • -IBD 2008; 14: 1236.  Anal skin tag description
  •  -JPGN 2005; 41: 667.  Discusses several cases of highly destructive perianal dz. -Gastro 2003; 125: 1503-1507, 1508-1530.  Technical review.
  • -Gastro 2003; 125: 291.  Bourne test to detect occult bladder fistula.  Following nondiagnostic barium enema, urine can be collected, centrifuged,  and xrayed to determine if there is  a connection.

 

Safety initiatives -the first 10 items

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A recent review (Ann Intern Med 2013; 158: 365-8) notes that “over the past 12 years, since the publication of the Institute of Medicine’s report, ‘To Err is Human: Building a Safer Health System, ‘ improving patient safety has been the focus of considerable public and professional interest.”  The following is a summary of this report (Epocrates docalert summary):

Patient-safety experts in North America and the U.K. systematically reviewed the growing evidence base for 158 patient-safety topics, including 41 strategies designated as most important to practitioners and patients. All reviews are published in the Agency for Healthcare Research and Quality (AHRQ) evidence report entitled “Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices” to update the original 2001 publication. After carefully analyzing each patient-safety problem and its related safety strategy, the authors strongly recommend immediate adoption of the following 10 strategies:

  • Preoperative and anesthesia checklists to prevent operative and postoperative events
  • Bundles (with checklists) to prevent central line–associated bloodstream infections
  • Interventions to reduce urinary catheter use
  • Bundles to prevent ventilator-associated pneumonia
  • Hand hygiene
  • Do-not-use list for hazardous abbreviations
  • Multicomponent interventions to prevent pressure ulcers
  • Barrier precautions to prevent healthcare-associated infections
  • Real-time ultrasonography for central line placement
  • Interventions to improve prophylaxis for venous thromboembolism

The authors also provide a list of 12 “encouraged” (rather than “strongly encouraged”) patient-safety practices, these are listed in Table 2 of the paper.

Abdominal distention – a medical mystery?

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A recent ‘think like a doctor’ case in the NY Times involved a patient sent to a pediatric gastroenterologist for abdominal distention.  It’s worth a read (thanks to Ben Enav for sharing this reference).

http://well.blogs.nytimes.com/2013/09/05/think-like-a-doctor-the-gymnasts-big-belly/

With regard to bloating and distention, the ‘smartphrase’ that I use to discuss this issue with parents is based on the “5 Fs” that I learned during fellowship.  I decided to modify the phrase a little bit based on the above case:

” I reviewed the issue of bloating/distention with family. Typically, distention or bloating can be caused by “5 Fs” which include flatus (gas), feces (constipation), fluid, fat, and fetus/masses. Flatus can be caused by swallowing air (aerophagia), malabsorption (celiac, lactose intolerance, parasites), muscular discoordination (abdominal phrenic dyssynergia), and motility problems.”

Are there other etiologies that you discuss with your patients?

Not Understanding Medicare Spending

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A recent report (NEJM 2013; 369: 1066-1073) highlights the lack of understanding regarding the costs of Medicare and the political problems ahead for those who try to reduce these costs.  The data the authors provide is derived from six public opinion polls in 2013 with 1013 to 2017 U.S. adults along with historical data.

Key points:

  • 62% believe Medicare spending is rising faster than it was 5 years ago –it’s not.
  • The three top reasons why the public thinks Medicare has rising costs: poor government management, fraud and abuse, and excessive charges by hospitals .
  • Only 53% are aware that it is one of the largest federal budget items.
  • Only 31% believe it is a major cause of the deficit.
  • Two thirds of respondents believe that most Medicare recipients get benefits worth about the same (27%) or less (41%) than what they have paid in payroll taxes/premiums.  In fact, “Medicare beneficiaries on average pay approximately $1 for every $3 in benefits.”
  • Political implications: among registered voters, 12% say they would be more likely to vote for a congressional candidate who favored cuts in Medicare spending to reduce  the federal budget deficit compared with 58% who be less likely to vote for that individual.

Take-home message: Expectations to solve all of Medicare’s projected costs/financial sustainability by eliminating mismanagement along with fraud and abuse are misguided.  A better public understanding of Medicare’s finances would aid the long-term resolution of these issues.

Related blog post:

Esophageal distensibility with FLIP and EoE disease severity

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In patients with eosinophilic esophagitis (EoE), the development of fibrosis due to ongoing inflammation is one of the concerns as this can lead to more difficulty with swallowing,  food impactions, a smaller caliber esophagus, and stricturing.  A recent report highlights a way to measure esophageal distensibility and its correlation with disease severity (Clin Gastroenterol Hepatol 2013; 11: 1101-7).

This report describes the evaluation of 70 patients with EoE (ages 18-68 years with median of 38 years`, 50 men) who underwent endoscopy along with high-resolution impedance planimetry.  The average followup was 9.2 months. The functioning luminal imaging probe (FLIP) system was used after the endoscopy by placing a catheter transorally.  The catheter had 16 ring electrodes spaced 5-mm apart in the 8-cm measured segment.  The FLIP distal recording began 3 cm proximal to the esophageal gastric junction.  Esophageal cross-sectional areas were measured during 2-mL stepwise distentions and increasing to a maximum of 40 mL.

Patient EoE Clinical Features at baseline:

  • 26 patients had a history of food impaction
  • 37 patients had dysphagia
  • 5 patients had chest pain
  • 2 patients had heartburn
  • Ringed esophagus: 9 (13%) had severe endoscopic findings, 17 (24%) had moderate endoscopic findings, 40 (57%) had mild endoscopic findings
  • Primary treatment: PPI treatment (78%), Topical steroids (10%), diet 4 (6%)

Key findings:

  • Patients with food impaction had significantly lower distensibility plateau (DP) than those with solid dysphagia alone (see manuscript Figure 1).
  • Mean DP in food impaction 113 mm2 compared with 229 mm2 for those without a history of food impaction
  • The severity of mucosal eosinophilia did not correlate with risk for food impaction, distensibility, or requirement for dilatation.

In many ways, the findings are completely obvious.  If an individuals esophagus is less distensible, it makes sense that food could get stuck. However, the article highlights a novel way of assessing esophageal distensibility in this population.  While the study did not identify higher mucosal eosinophilia as a marker of distensibility, this may be a precursor to future problems.  In the discussion, the authors note that a 12.5 mm barium tablet test correlates with a 125-mm2 threshold. Thus, their data suggest a corresponding diameter of 17 mm as a prerequisite to avoid food impactions.

Bottomline: this study identifies a new way to assess the risk for food impactions in EoE by measuring esophageal distensibility.

Related blog entries:

Practical Advice on Enteral Nutrition

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In a previous post (NASPGHAN: Enteral Nutrition for Crohn’s Remission | gutsandgrowth), this blog provided a link to NASPGHAN information on enteral nutrition. Having reviewed this information further, I wanted to post some more information about one of the references which offers a terrific professional-quality 32 minute video (from IWK Health Centre in Canada).  This You-tube video on tube feeds provides interviews mostly from kids/family members along with some input by physicians and nutritionists; it is a fabulous resource for families weighing the option of tube feeds.  Around minute 23, a teen walks through the process of NG placement including advice on taping.  Around minute 31, a number of written tips are given like cleaning tubing with vinegar (& then rinsing with water).  According to the website there were only 275 views when I had clicked on this.  If that is accurate, it is a real shame.

Here’s the link:

Crohn’s Survival Guide: The Real Deal on Tube Feeds – YouTube

Other information from the NASPGHAN handout (which offers CME) in the link above:

  • Duration of enteral nutrition to induce remission: 8-12 weeks.  Enteral nutrition can induce remission in about 80% and is similar in effectiveness as corticosteroids.
  • Caloric needs: typically 120% of recommended daily allowance
  • Other foods? usually allowed water or clears like sodas, soup broth, and popsicles.  In some studies, up to 10% of energy intake as various other foods have been allowed; however, this creates a lot of difficulty monitoring.
  • Maintenance strategies: partial enteral nutrition (nighttime feeds only) can reduce recurrence.  More typical approaches included maintenance medication for long-term treatment, or enteral therapy in combination with maintenance medical therapy.  Alternatively, maintenance treatment can be instituted with cycles of 1 month exclusive enteral nutrition every few months.
  • What type of formula for NG tube? most commonly polymeric formulas
  • Refeeding syndrome: in children with severe malnutrition institution of tube feedings should be instituted more slowly over several days with electrolyte monitoring.

Tracking down a serial killer

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Truth be told, I really do like the murder mystery genre.  In medicine, that particular type of drama is usually absent.  Nevertheless, it is fascinating when epidemiologists can track down an agent responsible for multiple deaths and widespread illness.  The latest example: Listeria monocytogenes (NEJM 2013; 369:  944-53).

This recent report isolated Listeria monocytogenes as the agent responsible for 147 outbreak-related cases in 28 states; there were 33 deaths.  The investigators used multistage epidemiological, trace-back, and environmental studies.  Molecular finger printing of the cases identified five distinct patterns which defined the outbreak cases. By comparing the outbreak cases to sporadic cases using the “Listeria initiative,” the authors were able to determine that uncut cantaloupe ingestion was much more common among the outbreak-related cases.  Subsequently, the source of the contaminated cantaloupe were traced back to a Colorado  farm that had switched to a different cleaning method in 2011.

Other data:

  • Only 7 cases (5%) were pregnancy-associated; 1 miscarriage occurred
  • The median age was 77 years in this cohort.
  • Most of the deaths were in the elderly, with only 2 deaths occurring in individuals less than 60
  • 143 patients required hospitalization

While this report discussed 147 outbreak-related cases, there were undoubtedly many more outbreak-related cases which were unidentified due to milder illness.

Bottomline: this report provides a framework for identifying outbreaks of contaminated produce.  It reinforces the need for good agricultural practices to minimize food borne-pathogen infections. It is a good read.

Related blog posts:

PPIs in Neonates –Helpful?

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Acid suppression in infants has not been proven to be effective in reducing gastroesophageal reflux (GER) symptoms. In a systemic review, this was thought to be either “because the symptoms are not caused by GER or if due to GER, because the symptoms are caused by volume reflux, rather than acidity.”  This quote is noted in the background information of another study which came to the same conclusion (J Pediatr 2013; 163: 692-8).

The pharmaceutical-supported study enrolled neonates (n=52) at 3 centers with gestational ages between 28-44 weeks.  Half of the participants were randomized to esomeprazole (0.5 mg/kg/day) and half placebo.  GER symptoms that were required for enrollment included any 2 of the following:

  • apnea with or without bradycardia
  • apnea with or without oxygen desaturations
  • irritability/pain
  • vomiting/gagging

Participants underwent extensive testing with video monitoring, esophageal pH & impedance testing, and cardiorespiratory monitoring.  They were followed for 14 days.

Findings:

  • There were no significant differences in any GERD-related signs and symptoms.
  • The esomeprazole group had improvement in acid reflux parameters on testing at 7 days, including number of reflux episodes (35 –>23) and mean percent time with pH<4.0.  The latter change was -10.7% was statistically significant (p= .0017) compared to placebo group which had an increase in time with pH<4.0 (2.2% increase).
  • No new safety signals were identified.

Despite its widespread usage, the authors had difficulty enrolling a larger cohort.  The small sample size was one of the study’s limitations along with the 14-day study period.  This limitation also precludes conclusions regarding the safety of these medications in neonates.

Bottomline: this study adds to the growing body of evidence that proton pump inhibitors (PPIs) are not effective in infants with so-called ‘signs and symptoms of reflux.’  PPIs are effective at reducing acid exposure and could be helpful in proven mucosal disease (eg. esophagitis and gastritis).

Related blog entries: