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.

Fundamentals of Gastrostomy Tubes

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I Novak, NK Velazco. Pediatrics in Review; 2024: 45: 175-187. Gastrostomy Tubes: Indications, Types, and Care

Thanks to Patrick Reeves for sharing this reference. While reading this article, I was reminded of Debbie Mason RN. She worked mainly for Colin Rudolph when I was a fellow at Cincinnati. She would teach the fellows the ‘ins and outs’ regarding gastrostomy tubes (GTs).

Some of the points from this article:

  • Background: In one large study, 25% of hospitalized pediatric patients in 63 U.S. hospitals required a temporary NG tube. GTs “preferred for longer-term access due to being less prone to accidental dislodgement, blockage, and interruption of feeds. They are also more durable, discrete, and avoid nasal trauma.” They are probably safer too for longer-term use. (An omission in the article: AMT bridles can help maintain NGs.)
  • Indications: Reviews the extensive list of reasons for GT placement, most related to inadequate nutritional intake (related to many chronic disease processes)
  • Contraindications are reviewed. “Absolute contraindications include active sepsis or peritonitis, massive ascites, uncorrectable coagulopathy, portal hypertension with significant varices, and history of total gastrectomy.” Transoral PEG tube is contraindicated, as well, if pharyngeal or esophageal obstruction, malrotation, or colonic interposition.
  • Preprocedural evaluation is described. Some have recommended UGI prior to placement in those with congenital anomalies. Others have stated that “even congenital anomalies should not mandate an upper GI series given how rare malrotation is in general.” Many children benefit from NG feeding trials prior to GT placement which can also improve nutritional status preoperatively.
  • The placement methods and types of GTs are reviewed. “As of now, there is no clearly identified optimal technique” (eg. laparoscopic GT vs PEG). The others note a meta-analysis of 22 studies (n >5000) found a higher rate of major complications with PEG placement. The authors recommend T-fasteners if GT balloon is used for initial placement.
  • Examples of bolster-type (non-balloon) GTs:
  • GT complications are discussed including infection, peritonitis, bleeding (rare to need a transfusion), injury to adjacent organs, pneumoperitoneum (usually benign and transient), hypergranulation, cellulitis (often treated with a first-generation cephalosporin or topical mupirocin), dislodgement, tube migration, and buried bumper syndrome. For early dislodgement (especially first 4-6 weeks after placement), blind reinsertion should be avoided.
  • GT care: The authors recommend starting feeds “not more than 3 to 6 hours” after placement to monitor for immediate postoperative complications, and cleaning site with warm water, saline or soap. Once the site has healed showering and bathing can resume; swimming can be permitted a few weeks after placement. Medications should be given via gastric port (if GJ) for better absorption of medications and lessen risk of tube clogging.
  • Troubleshooting: This is the most useful part of this article. Advice on peristomal leakage: “Placing larger tubes should be avoided because this will only enlarge the stoma tract…removal of the tube for a few hours can be considered because this permits the tract to start closing.” Leakage is often due to issues with balloon volume, poor fit, gastric pressure (eg dysmotility, gastroparesis) and poor wound healing. Clogging: “Carbonated beverages, juices, and meat tenderizer…studies have not shown these to be effective.” Lukewarm water, left to stand 20 minutes, is the first line agent for declogging. Other options include commercial enzymatic decloggers, and mechanical decloggers.
  • GT removal is discussed and I disagree with the authors that “persistent gastrocutaneous fistulas are rare after removal” (though the majority will close with conservative management). The authors do not recommend cutting GT bolsters due to risk of obstruction and note that endoscopic removal is often necessary.

My take: This article would be well-positioned as part of any GI fellows’ required curriculum and has a bunch of pointers for experienced clinicians as well. It could easily be used for material for ABP questions too. The article is much more detailed than the summary I have provided.

Also, another relevant resource (not discussed in article): Oley Foundation (oley.org). This foundation aims to help those living with home IV nutrition or tube feeding through advocacy, education, community and innovation.

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Dr. Joel Rosh: Positioning Therapies for Pediatric Ulcerative Colitis

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Dr. Joel Rosh gave our group an excellent update on sequencing therapy for ulcerative colitis (UC).  My notes below may contain errors in transcription and in omission. Along with my notes, I have included many of his slides.

  • There are only two FDA-approved biologics in pediatric Ulcerative Colitis. It typically takes 8-10 years for a medication with approval in adults to receive FDA approval in children
  • The concept of IBD as two diseases, Crohn’s disease and UC, is flawed; there are more than 200 susceptibility genes for inflammatory bowel disease
  • There has been an increasing incidence and prevalence of IBD. Some of this increase is likely due to our diet and its effects on the microbiome
  • Ultrasound is a nice tool to see what is going on in real time and shows that UC is really a transmural disease.  UC changes in the bowel can result in fibrosis
  • Consider cytokine-basis for disease as a way to conceptualize disease presentation compared to organ-based disease. Many autoimmune diseases (eg. JIA, RA, Psoriasis) are different manifestations related to cytokine-based autoimmunity
  • Almost all pediatric IBD can be considered higher risk based on known risk factors including disease extent (>80% of pediatric UC is pancolitis) and disease age of onset
  • Mesalamine steroid-free clinical remission rates are about 1/3rd after 1 year of treatment
  • Overall, there has been an improvement in colectomy rates since 2001; there still appears to be a bump in the colectomy rate after having UC for more than 10 years
  • Elevated CRP is less common in patients with UC, compared to Crohn’s disease, and is a marker for more severe disease activity
  • Dr. Rosh prefers to avoid some terms including biologic-naive and steroid failure; he favors biologic-unexposed for the former. For the latter, he tries to make it clear that the patient was not a steroid failure. Steroids failed the patient rather than the patient failing the steroids
  • Therapeutic drug monitoring (TDM) is mainly beneficial for anti-TNF agents at this time. Use of TDM can help monotherapy achieve similar results as combination therapy. For infliximab, Dr. Rosh’s ‘rule of thumb’ is 28-18-8 for 2 week trough, 6 week trough, and maintenance trough. Therapeutic levels will meet or exceed these trough levels.
  • Combination therapy has not been shown to improve pharmacokinetics for vedolizumab or ustekinumab
  • Generally, a washout period is not needed when changing biologic therapies. In fact, having some overlap in the medications may have some therapeutic benefit
  • Upadacitinib (Rinvoq) appears to be the most effective JAK for IBD. It is labelled for use as a 2nd-line agent but may be superior for some sicker patients. Rinvoq could be considered as a ‘bridge’ medication in patients with acute severe ulcerative colitis with transition to another biologic like vedolizumab
  • It is important for families to be informed that there is a black box warning for the use of JAK inhibitors. However, major cardiac adverse events (MACE) do not appear to be increased in patients without preexisting cardiac disease risk factors

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Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  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.

The Naismiths of Endoscopy

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The pioneers of endoscopy are discussed in the following article:

AR Schulman, JD Howell. Clin Gastroenterol Hepatol 2024; 22: 684-688.Open Access! From Hirschowitz to 2023: Modern Endoscopy and Beyond

A few excerpts:

  • “In 1868, the German physician Adolph Kussmaul looked inside the stomach of a human being. He chose to peruse the stomach of a professional sword-swallower, someone who was able to tolerate, although probably not to enjoy, a straight, 47-cm long metal tube with a diameter of 13 mm.1 This marked the beginning of the first era of endoscopy, the era of rigid endoscopy…encountered 2 fundamental problems. One, although a metal tube is straight, the gastrointestinal tract is not. And, two, the inside of the human body is dark.”
  • “Rudolf Schindler, working in Munich, realized that the rigid gastroscope “never could be routinely used.”2 In 1932 he designed a semiflexible endoscope, an invention that marked the beginning of the second era of endoscopy…[after surviving Dachau concentration camp], he settled at the University of Chicago.3“
  • “In 1954, [Basil] Hirschowitz learned that it might be possible to create a device that could transmit optical images along a flexible axis. Working with 2 colleagues from the University of Michigan Physics Department, which was located not far from the Medical School, he created a prototype device for looking into the stomach.”

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Do We Need Documented Consent to Do a Rectal Exam for a Pediatric Patient?

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AGA 4/10/24: New NHS Guidance on Informed Consent consent impacts GIs

My take: This guidance likely was derived from patients having sensitive exams without permission while under anesthesia. While this guidance is directed at hospital settings and hospital-based outpatient clinics where written consent is now needed, practitioners in the outpatient setting likely will need to better document permission prior to rectal examination and assure appropriate use of chaperones.

Resources:

Related blog post: Don’t Let the Chief of Staff Review This Constipation Study

Proactive Monitoring Associated with Higher Rates of Transmural Healing

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SR Fernades et al. Inflammatory Bowel Diseases, izad272, https://doi.org/10.1093/ibd/izad272 Proactive Infliximab Monitoring Improves the Rates of Transmural Remission in Crohn’s Disease: A Propensity Score–Matched Analysis 

Methods: Retrospective cohort study (n=195) including consecutive CD patients starting treatment with IFX. Rates of transmural remission were compared between patients with and without therapeutic drug monitoring (target level: 5-7 µg/mL).

Key findings:

  • The rates of transmural remission were higher in patients under proactive therapeutic drug monitoring (37.2% vs 18.3%; P = .004) with similar results in the propensity score–matched analysis (34.2% vs 17.1%; P = .025). 
  • In multivariate analysis, proactive therapeutic drug monitoring was independently associated with transmural remission (odds ratio, 2.95)

My take: Proactive therapeutic monitoring is beneficial in improving outcomes in patients with Crohn’s disease. Higher drug levels are likely to be particularly important to achieve adequate tissue penetration in transmural Crohn’s disease.

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Ram Head Trail, St John

What We Don’t Know About Toxic Exposures is a Lot and Dangerous

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TJ Woodruff. NEJM 2024; 390: 922-933. Health Effects of Fossil Fuel–Derived Endocrine Disruptors

Initially, I was tempted to title this post ‘Burying the Evidence and the Bodies from Pollution.’ That sounded too alarmist, though. That said, this review article asserts that “chemical pollution is estimated to be responsible for at least 1.8 million deaths each year…This number is probably an underestimate, since less than 5% of approximately 350,000 chemicals registered for use globally have been adequately studied.1”  (90% of pollution-related deaths occurring in low- and middle-income countries).

In addition, “polluting industries [are] “weaponizing” scientific uncertainty to foster distrust in scientific findings and lobbying for weaker regulations.71 For example, previously secret industry documents show that the industries knew about the health harms of PFAS decades before the scientific and public health community did.72” The science behind pollution is hampered by the inability (unethical) to conduct randomized trials of pollution exposure.

This article focuses on Endocrine Disruptors Chemicals (EDCs).

Health Effects of Fossil Fuel–Derived Endocrine Disruptors

  • Fossil fuels contribute to chemical pollution through production of petrochemicals, many of which interfere with hormonal function (endocrine-disrupting chemicals [EDCs]). Examples include perfluoroalkyl and polyfluoroalkyl substances in food packaging and fabrics and phthalates in plastics and consumer products.
  • Petrochemical production is increasing, and people are exposed through contaminated air, water, food, and manufactured products (e.g., plastics, pesticides, building materials, and cosmetics).
  • EDCs can increase several health risks, including cancer, neurodevelopmental harm, and infertility.
  • Risks are higher with exposures during fetal and child development and with exposure to multiple EDCs and occur at low exposure levels. Exposures are higher in communities of color and low-income communities and contribute to health inequities.
  • Clinicians can provide advice to patients toward reducing some exposures, but policy change is needed to establish legal requirements for comprehensive safety testing and to reduce health threats from petrochemicals. Clinicians are important advocates for these changes.

Figure 2 reviews the potential individual modifiers to the effects of pollution as well as the increased adverse health effects.

Table 2 provides recommendations for reducing exposures including diet/food preparation, cleaning/use of cleaning products, minimizing occupational exposures, and advocacy.

My take: There are limited steps that individuals can take to reduce their exposures. In order to make our environment safer, this requires policy changes. Most individuals do not even know if they are being exposed to dangerous pollutants and would have limited ability to move away from unsafe areas.

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Increased Risk of Irritable Bowel Before and After the Diagnosis of Celiac Disease

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K Marild et al. Clin Gastroenterol Hepatol 2024; Open Access (PDF)! Association Between Celiac Disease and Irritable Bowel Syndrome: A Nationwide Cohort Study

Methods: Using Swedish histopathology and register-based data, we identified 27,262 patients with CD diagnosed in 2002–2017 and 132,922 age- and sex-matched general population comparators.

Key Findings:

  • During an average of 11.1 years of follow-up, 732 celiac patients (2.7%) were diagnosed with IBS vs 1131 matched general population comparators (0.9%).
  • Compared with siblings (n= 32,010), celiac patients (n = 19,211) had >/= 2-fold risk of later IBS (aHR, 2.42)
  • Compared with celiac patients with mucosal healing, those with persistent villus atrophy on follow-up biopsy were less likely to be diagnosed with IBS (aHR, 0.66)

Interpretation of findings:

“We found celiac patients with persistent villus atrophy on follow-up biopsy less likely to be
diagnosed with IBS than those with mucosal healing. Traditionally, physicians have hesitated to diagnose IBS in patients with an organic gastrointestinal disorder (eg, CD), possibly underestimating the observed IBS risk in CD. This reluctance to diagnose IBS may be particularly true for celiac patients who have not achieved mucosal healing, because persistent villus atrophy may indicate that ongoing symptoms are due to gluten exposure
instead of IBS.”

“Surveillance bias is another challenge of studies associating IBS with CD. From the outset of diagnosing and managing these conditions, they are often mutually excluded (eg, CD-specific serology tests are often part of the workup of IBS-like symptoms). Consequently, the
strength of the association between these conditions may be overestimated.” This is why the authors focused on IBS events beyond the first year of CD diagnosis and there continue to be an increased risk of IBS 10 years of follow-up.

Another limitation of this study: “a large proportion of IBS patients are cared for in
primary care or never seek care at all, and hence our study may have had a low sensitivity for IBS, particularly mild IBS.”

My take: While recurrent symptoms in patients with CD could indicate ongoing gluten exposure, recurrent symptoms can also be due to IBS which can occur even with mucosal healing.

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Mike Farrell and The Role of The Consultant

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Jose Garza recently shared this lecture from one of our mentors, Mike Farrell. I really enjoyed being able to hear and see him. This lecture discusses the role of being a consultant and how many things have changed over the years. It is amazing that Mike has been at Cincinnati for 50 years and has instructed so many residents, clinicians as well as GI trainees. The main task is still providing assistance to our colleagues in a respectful manner. I’ve included some of his slides.

Link: The Consultation: An Ancient and Venerable Process in the Modern Age

Often, the person requesting the consult does not know exactly why they are requesting a consult.
Dr. Farrell recommended documentation with phone consultation that patient
was not examined and to please call back if needed and patient could be seen.
Dr. Farrell says he often starts a visit with a family by asking ‘How Can I Help You?’
On the left: Dr. Schubert (one of Dr. Farrell’s mentors).
On the right: Christine Heubi, Jim Heubi, Mike Farrell and Peter Farrell.

On a separate note, Mike was honored recently by Cincinnati Children’s with the Drake Medal. Link: Mike Farrell, Recipient of Drake Medal Some of the accomplishments noted in this article:

  • Among the first to study the relationship between infantile apnea and gastroesophageal reflux
  • Helped define the hepatobiliary complications associated with parenteral nutrition
  • Participated in important studies defining vitamin D, calcium and phosphorus requirements in infant parenteral nutrition solutions
  • Invented the Farrell Valve Enteral Gastric Pressure Relief System, aka the Farrell bag—a disposable plastic bag that is connected to vent a feeding tube, which is now used nationwide.
  • Presented with the 2007 Murray Davidson Award from the American Academy of Pediatrics (AAP)

Improved Efficacy with Vonoprazan for Severe Esophagitis

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Briefly noted:

Q Zhuang et al. The American Journal of Gastroenterology  :10.14309/ajg.0000000000002714, March 22, 2024. Comparative Efficacy of P-CAB vs Proton Pump Inhibitors for Grade C/D Esophagitis: A Systematic Review and Network Meta-analysis

In this meta-analysis, 24 studies met criteria. Key findings:

  • Vonoprazan (20 mg) had the lowest rates of treatment failure: 6% in the initial treatment phase, and 21% in the maintenance phase of healing of grade C/D esophagitis
  • Vonoprazan had similar risk of incurring adverse events, severe adverse events, and withdrawal to drug when compared with PPI.

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Tofacitinib vs Ustekinumab -Which is Better for Ulcerative Colitis?

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RS Dalal et al. Inflammatory Bowel Diseases, Volume 30, Issue 3, March 2024, Pages 395–401. 1-Year Comparative Effectiveness of Tofacitinib vs Ustekinumab for Patients With Ulcerative Colitis and Prior Antitumor Necrosis Factor Failure

In this real-world cohort of anti-TNF-exposed patients with ulcerative colitis, tofacitinib (n=69) and ustekinumab (n=97) demonstrated similar effectiveness in achieving steroid-free clinical remission (SCFR) at 12 and 52 weeks. The median follow-up was 88.0 and 62.0 week, respectively. 35 of 66 in the tofacitinib cohort had dose reduction from the starting dose of 10 mg twice daily. This reduction occurred at a mean of 144 days. 59 of 97 in the ustekinumab cohort received either Q4W dosing (n=43) or Q6W (n=16).

Key findings:

  • 53% of patients receiving tofacitinib and 32% of patients receiving ustekinumab achieved SFCR at 12 weeks. Tofacitinib-treated patients had higher baseline Mayo endoscopic subscores and CRPs.
  • At 52 weeks, approximately 50% of patients in both treatment groups achieved SFCR. There were also high proportions (>60%) of patients in both treatment groups who had endoscopic response within 52 weeks.
  • Both drugs were well-tolerated, as only 1 patient in each treatment group discontinued therapy due to an AE during >260 patient-years of follow-up.

My take: This shows similar response to either tofacitinib and ustekinumab in a cohort that had refractory disease as patients were anti-TNF failures and most had prior vedolizumab as well.

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