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.

Duodenal IELs and the likelihood of celiac disease

Posted on February 14, 2013 by gutsandgrowth

The diagnosis of celiac disease has definitely become more complex due to the interplay of serology, genetic markers, clinical response to gluten-free diets, and histology. The Mayo clinic pediatric experience with duodenal intraepithelial lymphocytosis (IELs) with normal villous architecture highlights this issue (JPGN 2013; 56: 51-55).

Between 2000-2009, 56 children from the Mayo clinic pathology database of duodenal biopsies (n=1290) were identified. Among this group, 48 had serological testing for celiac disease (CD). Ultimately, 9 were labeled with CD, though only 5 met the ‘definite’ criteria. Other conditions that were associated with increased IELs included the following:

Medication exposure
Inflammatory bowel disease
H pylori infection
Autoimmune conditions
IgA deficiency

So, which patients with duodenal IELs had CD?

“Definite” CD was used to define patients with elevations in two different serologic markers (TTG and EMA) or those with elevation in one serologic marker along with a documented clinical response to a gluten-free diet (GFD).
“Possible” CD described patients with normal serology, but serologic titer and clinical response was noted on a GFD.
“Unlikely” CD categorized patients with two negative serology markers who had compatible human leukocyte antigen haplotype and had clinical response to GFD.

In addition, if the IELs were predominantly on the villi tips, this increased the likelihood of CD.

Related blog posts:

Three PEG Pediatric Cleanouts

Posted on February 13, 2013 by gutsandgrowth

Several articles highlight the use of polyethylene glycol (Miralax) as a bowel prep for children:

JPGN 2013; 56: 215-19
JPGN 2013; 56: 220-24
JPGN 2013; 56: 225-28

These studies and the accompanying editorial (pg 115) show fairly good results with PEG cleanout regimens.

The first study compared PEG versus senna in a blinded, prospective randomized trial. After enrolling 30 children (6-21 years of age) at a planned interim analysis, the study showed superiority of PEG (1.5 g/kg/day) when used for 2 days prior to colonoscopy. In addition to laxatives, patients were instructed to consume full liquid diet for 2 days prior to procedure & clear liquid on day prior (up to 3 hours before procedure). In the PEG group, good or excellent cleanout scores were noted in 88% compared with only 29% in the senna group. There were no significant adverse effects or electrolyte changes which are well-detailed in this study (Table 2).

The second study evaluated a 1-day regimen with 46 children in a prospective open-label study. 238 g of PEG was mixed with 1.9 L of gatorade and administered over several hours. Patients (8-18 years) were instructed to take only clears after noon the day prior to procedure Only 37 (82%) were able to take the full preparation. 43 (93%) took at least 75% of the preparation. Despite issues with tolerance and nausea/vomiting (noted in 60%), 77% were rated as having an effective cleanout.

The third study enrolled 45 children (5-21 years) in a prospective study of a 1-day bowel preparation. Patients <45 kg received 136 g of PEG solution with 32 ounces of Gatorade; patients >45 kg received 255 g in 64 ounces. 44 children completed study. Patients were told to take PEG over 3 hours the evening prior to procedure and allowed clears until 3 hours prior to procedure. In this group, nausea was noted in 34% and vomiting in 16%. However, patients reported that preparation was easy in 61% and tolerable in 39%. The quality of the preparation was considered excellent in 23%, good in 52%, fair in 23% and poor in 2%. There were no significant electrolyte changes.

Take Home Message:

Numerous small studies show that PEG solutions can be used as a safe, effective bowel preparation in children. Shorter duration preparations are more convenient and may result in nausea or vomiting.

In our institution, we frequently use PEG cleanouts. However, typically our doses of PEG are lower (eg. 136-168 g) and often combined with an enema to complete cleanout process. Unlike adult preparations, we have not instructed families in split-dose regimens mainly due to concerns about the ability of pediatric patients to adhere to these regimens.

Related blog entry:

Colonoscopy, Split–dosing bowel preps, and Ottawa scores …

Miralax Safety

Posted on February 12, 2013 by gutsandgrowth

Periodically questions about the safety of Miralax arise. Recently, several colleagues have received some questions about the use of Miralax due to information on the internet. You may want to familiarize yourself with this link due to the misinformation which is provided:

http://www.gutsense.org/gutsense/the-role-of-miralax-laxative-in-autism-dementia-alzheimer.html

Some of the misleading statements:

Miralax has never been tested for safety in children
Miralax makes one cancer-prone by leaving the colon unprotected
Miralax may result in severe malnutrition ..leading to Autism
Miralax can cause memory loss and neurologic side effects

It is true that there is not enough adequate long-term data on the use of Miralax, though there are studies showing its effectiveness/safety (see below). However, according to the FDA, there are no neuropsychiatric warnings needed for Miralax:

http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Surveillance/AdverseDrugEffects/ucm295585.htm

As with all medications, one has to weigh the risks and the benefits. Clearly, the risk and consequences of untreated defecation problems can be severe in some children and may have terrible adverse effects on daily living. The known safety profile of Miralax is very good and its usage has been recommended by the American Gastroenterological Association (AGA) and by the North American Society for Pediatric Gastroenterology Hepatology and Nutrition (NASPGHAN) in position statements on the treatment of constipation:

An article from NY Times on this subject:

Miralax, a Drug for Adults, Is Popular as a Children’s Remedy …

AGA Constipation Guidelines

Posted on February 11, 2013 by gutsandgrowth

Constipation is a ubiquitous problem. Updated guidelines and a technical review for adults with constipation have been published (Gastroenterol 2013; 144: 211-17, Gastroenterol 2013; 144: 218-38). AGA Institute Policy and Position Statements – Gastroenterology …

For pediatric gastroenterologists, the 2006 NASPGHAN guidelines (Evaluation and Treatment of Constipation – North American Soci) are more useful. Nevertheless, these AGA guidelines offer some helpful insights.

Definition: “physicians often regard constipation to be synonymous with infrequent bowel movements, typically fewer than 3 per week, patients have a broader set of symptoms” that are considered constipation including hard stools, abdominal discomfort, incomplete evacuation, and excessive straining. Rome III criteria: “symptoms for ≥ 6 months and ≥ 2 of the following symptoms for more than one-fourth of defecations during the past 3 months: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual maneuvers to facilitate defecations; ❤ defecations/wk, loose stools are not present and there are insufficient criteria for IBS”

In adults, medical testing:

“In the absence of other symptoms and signs, only a complete blood count is necessary.” Not needed unless other features: TSH, calcium, colonoscopy
Anorectal manometry and rectal balloon expulsion should be performed in patients who fail to respond to laxatives. Defocography should be considered subsequently. Colonic transit should be evaluated if anorectal test results do not show a defecatory disorder.

Recommended Treatment:

Start with increased fiber and laxatives (e.g. PEG, milk of magnesia, bisacodyl). Newer pharmaceutical agents (e.g. lubiprostone and linaclotide) can be considered if no improvement.
Both “normal transit constipation and slow transit constipation can be safely managed with long-term use of laxatives.” (strong recommendation, moderate-quality evidence). “Contrary to earlier studies, stimulant laxatives (senna, bisacodyl) do not appear to damage the enteric nervous system. Neurologic damage might just as readily be the cause, not the result.”
Pelvic floor retraining by biofeedback rather than laxatives is recommended for defecatory disorders
Additional workup in those who do not respond. Surgical treatment of slow transit constipation (subtotal colectomy or colectomy with ileorectal anastomosis) only when well-documented failure of aggressive prolonged laxatives/prokinetics

The technical review has a table that lists medications associated with constipation, describes pathophysiology in detail, lists the conditions associated with constipation, and explains the testing/medical management in-depth.

Related blog entries:

PEG vs. Fiber for constipation | gutsandgrowth
Stimulants for constipation | gutsandgrowth
It’s worth the cost | gutsandgrowth
ACE report -10 year effectiveness | gutsandgrowth
Linaclotide –not for kids | gutsandgrowth
Clues about constipation and more than 2.5 million … – gutsandgrowth

Is fasting needed before checking lipids?

Posted on February 10, 2013 by gutsandgrowth

Not really. According to a recent study involving 209,180 individuals, fasting times showed little association with lipid levels in a community-based population (Arch Intern Med 2012; 172: 1707-10).

Although current guidelines suggest obtaining lipid levels after fasting, lipid levels do not vary much between fasting and nonfasting states. Furthermore, fasting may not be reflective of the patient’s typical metabolic state.

Design: cross-sectional study over a 6-month period in 2011 (Calgary) using a large community-based cohort. The average age of the participants was 52.8 years.

Results: In tables 1 and 2, the authors provide the cholesterol values for fasting times that varied from 1 hour to 16 hour. The vast majority fasted for 10 hours or more. For example, less than 1% of the cohort fasted for only 1 hour. However, fasting time showed little association with lipid subclass levels, suggesting that fasting for routine levels is not necessary.

There were several limitations of the study. The meal choices in the nonfasting groups were not known and the study was not randomized. In addition, LDL values were not calculated when triglycerides were >400 mg/dL; this represented 1.5% of the study population. The authors recommend that in individuals with triglycerides >400 mg/dL that fasting lipid levels could be considered.

Related blog entries:

Microbiome and the risk of Kwashiokor

Posted on February 9, 2013 by gutsandgrowth

On the way home from work, NPR highlighted a study that suggests that altered microbiome may increase the risk of Kwashiokor (Gut Microbes May Play Deadly Role In Malnutrition : Shots … – NPR).

Interestingly, a separate article indicates that antibiotics lowers the mortality in severe acute malnutrition (NEJM 2013; 368: 425-35). In this study, 2767 children from 18 feeding clinics in Malawi (2009-2011) were enrolled in a randomized, double-blind, placebo-controlled trial. Children were 6 to 59 months of age with severe acute malnutrition. Those who received amoxicillin, cefdinir, and placebo recovered in 88.7%, 90.9%, and 85.1% respectively. The relative risk of death in the placebo group was 1.55 compared to amoxicillin and 1.80 compared to cefdinir. The children in the antibiotic group also had improved growth.

The authors suggest that the reason for improvement is likely to be due to fewer invasive bacterial infections. These infections are frequent and thought to be related to translocation across compromised mucosal surfaces. However, perhaps the antibiotics act by producing a more favorable microbiome which in turn promotes improvement. As such, microbes have a role in contributing to obesity (Microbial transfer for metabolic syndrome? | gutsandgrowth) and to starvation.

Related Link:

Gut Microbiomes of Malawian Twin Pairs Discordant for Kwashiorkor abstract in Science

Physician narrative on gun control

Posted on February 8, 2013 by gutsandgrowth

Recent commentaries offer several physician viewpoints on this problem (NEJM 2013; 368: 397-99, 399-400, 401-403). For me, the following points were of most interest:

88 Americans died every day from firearm violence in 2011; high-profile events like Sandy Hook, Aurora, Virginia Tech and Columbine are uncommon.
In California, background checks are required on all firearm purchases and this has been associated with a 23% reduction in firearm-related crime. Though, this policy is hampered by neighboring state policies. In Reno, Nevada, about 1/3rd of the cars at gun shows are from California.
In 2010, 6570 deaths in children/young persons (1-24 yrs) were due to gun-related injuries. Gun-related fatalities cause twice as many deaths as cancer, five times as many as heart disease, and fifteen times as many as infections.
Suicide attempts with drugs are lethal in <5% whereas 90% involving guns are lethal.
The authors advocate for better background checks, a ban on assault weapons, limits on ammunition capacity, and removing restrictions on the collection of public health data regarding gun-related injuries.

In a previous blog about the problem of obesity, I referenced the “issue-attention cycle” problem. ”This pattern occurs when initial public alarm over the discovery of a problem and optimism about its quick resolution are replaced by the realization that solving the problem will require some public sacrifice and will displace powerful societal interests.”

Despite the high toll exacted by gun violence, will there be enough staying power to work on these incremental steps?

Where is the Journal Editor?

Posted on February 7, 2013 by gutsandgrowth

A recent article is titled “Determination of Bone Age in Pediatric Patients with Crohn’s Disease Should Become Part of Routine Care” (Inflamm Bowel Dis 2013; 19: 61-65). (Thanks to Ben Gold for suggesting this reference.)

Does the study merit the authors’ conclusion that ‘determination of bone age (BA) should become the standard of care in pediatric Crohn’s disease (CD) patients, allowing clinically meaningful interpretation of growth…leading to improved treatment recommendations?’

No. This small study (n=49, 84% Caucasian) simply showed that a lot of pediatric CD patients have a delayed bone age. This is not a novel finding.

Specifically, the mean BA Z score was -1.40 ± 1.5 in this population and 41% had a BA Z score of < -2.0. This cross-sectional study was conducted between 2007-2009. Patients were consecutively approached for enrollment during this time period.

Clinical factors associated with delayed bone age included Caucasian race, Tanner stage 1-3, history of steroid exposure, colonic disease location, azathioprine/6-mercaptopurine usage, and female sex. Interestingly, these variables are not entirely consistent with prior studies in which male sex was associated with delayed bone age.

The reason why the conclusion is a far-reach is that there is no data in the study showing how bone age influences any clinical decision-making in these patients. There is no information on cost-effectiveness of their proposed “standard of care.” There is no longitudinal data to suggest that the delayed BA or the recognition of a delayed BA resulted in a different outcome.

My conclusion:

Many pediatric patients with CD have delayed BA and some may benefit from a BA determination. I think extrapolating a much broader conclusion from this study is not warranted.

More on NEC and SimplyThick

Posted on February 6, 2013 by gutsandgrowth

Recent NY Times article on SimplyThick (article referenced from Kipp Ellsworth):

“Warning Too Late for Some Babies”

http://well.blogs.nytimes.com/2013/02/04/warning-too-late-for-some-babies/?smid=tw-share

Previous related blog entry:

NEC and thickening agents | gutsandgrowth

Vitamin D deficiency and metabolism in pediatric Crohn’s disease

Posted on February 6, 2013 by gutsandgrowth

As noted in previous blog posts (see links below), vitamin D has received a great deal of attention with a number of chronic diseases. In this latest study from CHOP, the incidence and mechanisms of vitamin D deficiency in pediatric Crohn’s disease are explored (Inflamm Bowel Dis 2013; 19: 45-33).

At diagnosis (2002-2005), Crohn’s disease (CD) participants (n=78) had their serum vitamin D assays and parathyroid hormone (PTH) levels checked. Then, these values were sequentially followed at 6 months, 12 months, and a median of 43 months later (n=52). The average age of the CD patients was 12.7 years.

Key findings:

42% of CD participants were 25-OH D deficient (<20 ng/mL) with an odds ratio of 2.1 compared with controls.
Among patients with 25-OH D <30 ng/mL, CD patients had a lower PTH than controls.
At final visit, 3% remained 25-OH D deficient and PTH levels corrected.
Risk factors, besides CD, for vitamin D deficiency: black race (OR 10.4), visit in winter (OR 2.4), age 12 to <15 (OR 2.7), age >15 (OR 3.2). Greater disease activity was associated with lower vitamin D levels at baseline.

Implications of this study:

Vitamin D deficiency normally causes secondary hyperparathyroidism. With newly-diagnosed CD, there was a relative hypoparathyroidism that resolved with therapy. “It is conceivable that proinflammatory cytokines associated with CD …prevent an appropriate PTH response.”
The authors state that ‘vitamin D deficiency likely contributes to the pathogenesis of CD through effects on T and B lymphocyte, macrophage, and dendritic cell regulation.” Correcting vitamin D deficiency may improve CD treatment response in addition to potential improvements in bone health.

Related posts:

gutsandgrowth

Pediatric Gastroenterology

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