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.

Surgery Compared to Biologic Therapy for Crohn’s Disease

Posted on October 31, 2023 by gutsandgrowth

M Agrawal et al. Gastroenterol 2023; 165: 976-985. Open Access! Early Ileocecal Resection for Crohn’s Disease Is Associated With Improved Long-term Outcomes Compared With Anti-Tumor Necrosis Factor Therapy: A Population-Based Cohort Study

In this study from Denmark (2003-2018) using the Danish National Patient and Prescription Registries, the role of early ileocecal resection (CR), n=581, was compared with anti-TNF treatment, n=698. The primary outcome was a composite of ≥1 of the following: CD-related hospitalization, systemic corticosteroid exposure, CD-related surgery, and perianal CD. Only 178 patients (13.9%) were less than 17 years old. ICR cohort had surgery within 5 months of diagnosis in 85%, and in all within 1 yr of diagnosis. Key findings:

The risk of the composite outcome was 33% lower with ICR compared with anti-TNF (adjusted hazard ratio, 0.67; 95% confidence interval, 0.54–0.83). ICR was associated with reduced risk of systemic corticosteroid exposure and CD-related surgery, but not other secondary outcomes
Of individuals who underwent ICR, the Kaplan-Meier estimate of the proportion who postoperatively initiated IMM, initiated anti-TNF treatment, underwent another intestinal resection, or were on no treatment at 5 years of postoperative follow-up was 46.3%, 16.8%, 1.8% and 49.7%,
Of those who were initiated on infliximab as primary therapy, the Kaplan-Meier estimate of the proportion who underwent ICR, switched to a different biologic agent, or continued infliximab at 5 years of follow-up was 17.7%, 40.8%, and 47.3%

The authors note that their cohort had infrequent complicated disease: “Before ICR, 21% were diagnosed with a stricture, ileus, internal fistula, or abscess, indicative of complicated CD and representative of the real world. In contrast, only 1.7% in the anti-TNF group had complicated CD.”

My take: This study suggests that ICR may be a reasonable option in many cases of Crohn’s disease at an earlier stage rather than reserved for only those with refractory disease and complications. However, in pediatric patients, I would be more reluctant to start with a surgical approach given even longer time frame in which further surgery could be needed.

Related blog posts:

Do We Need to Reimmunize Patients (with IBD or Celiac) with Low Hepatitis B Surface Antibody Levels?

Posted on October 30, 2023 by gutsandgrowth

JA Ulrich et al. Clin Gastroenterol Hepatol 2023; 21: 2901-2907. Open Access! Effectiveness of Hepatitis B Vaccination for Patients With Inflammatory Bowel and Celiac Disease

In 2022, a study in JPGN showed that the rate of Hepatitis B virus (HBV) vaccination and immunity was similar in individuals with and without celiac disease (CD). In addition, there was no increased risk of HBV infection detected in CD patients. Thus, routinely checking hepatitis B status in all patients with CD was no longer justified. (See: Celiac Disease, Hepatitis B and Paul Harvey).

The same researchers in this study expand their findings to inflammatory bowel disease (IBD) and CD. In this retrospective cohort (2000-2019), using the Rochester Epidemiology Project which includes data from 162,847 residents. Key findings:

1264 incident cases of IBD/CD, only 6 HBV infections were diagnosed before the index date; 5 of the 6 had risk factors including IV drug use or living in endemic region.
No new HBV infection developed in any of 1258 patients with IBD/CD during a median follow-up of 9.4 years
The proportion of patients with HBV-protective titers (≥10 mIU/mL) decreased with time before plateauing, with protective titer rates of 45% at 5 up to 10 years and 41% at 15 up to 20 years after the last HBV vaccination. The control population with protective titers also decreased similarly with time though was consistently higher than the levels of patients with IBD/CD within 15 years after the last HBV vaccination

Context/Discussion:

Only 16% of vaccine recipients have measurable protective titers by age 18 years, according to the CDC.³²
“Time-related waning of Ab levels to HBV after vaccination has unclear clinical significance. Although screening persons for HBV immunity by using anti-HBs titers is widely accepted, prior study results have shown that cellular immunity can also provide long-term HBV protection, even in the setting of nonprotective titers.”
Reactivation of HBV is a well-documented complication of immunosuppression in patients with IBD, and screening for dormant infection is of paramount importance at diagnosis
Limitations: the study population had a low rate of HBV acquisition; thus, the study findings may not apply to areas with higher risk for HBV.

My take: This study shows that treating low hepatitis B surface antibody levels with reimmunization is likely NOT needed in either the IBD or the celiac disease population, except perhaps in those at high risk. Checking HBV status prior to immunosuppressive therapy, though, is still needed to prevent reactivation of HBV in those at risk.

#NASPGHAN23 Year in Review 2023

Posted on October 27, 2023 by gutsandgrowth

Yesterday’s post was meant to be published on Halloween –will need to fire my editor.

———-

One of the highlights of NASPGHAN’s annual meeting is the Year in Review lecture. Sandeep Gupta, the editor of JPGN, provided a fantastic review. Here are some of the slides:

AAP has recommended pharmacotherapy and bariatric surgery in selected adolescents at 12 yr and 13 yr respectively. Related blog post: Meds for Obesity: AAP Guidelines

Related blog post: Semaglutide in Adolescent Obesity

Related blog post: Oral GLP-1 Receptor Agonist for Obesity: Orforglipron

etinoids may reduce risk of asparginase-associated pancreatitis

Related blog post: Nonspecific Duodenal Histologic Findings Common in Children with Trisomy 21

Related blog post: Updated Nomenclature for Eosinophilic Gastrointestinal Diseases

Related blog post: I-SEE for Eosinophilic Esophagitis

Related blog post: When to Use Dupilumab for Eosinophilic Esophagitis: Multispecialty Guidelines

Related blog post: Short Bowel Syndrome is a Full Time Job

Related blog post: You No Longer Have Fatty Liver Disease-You Have Steatotic Liver Disease!

Related blog post: RNA Interference (Fazirsiran) for Liver Disease Associated with Alpha-1-Antitrypsin Deficiency

Related blog post: Which Diet is Best for Irritable Bowel Syndrome? A Randomized Trial

Related blog post: Constipation Action Plan: Better Instructions, Fewer Phone Calls

Related blog posts: Foreign Body Retrieval: You Never Know What You Will See, Foreign Bodies in Children -Expert Guidance, Sharp Objects in GI Tract & Good Outcomes

Treats (Tips) and Tricks for Using IBD Drugs in Patients with Hepatobiliary Comorbidities

Posted on October 26, 2023 by gutsandgrowth

S Massironi et al. Inflamm Bowel Dis 2023; 29: 1477-1487. Use of IBD Drugs in Patients With Hepatobiliary Comorbidities: Tips and Tricks

This review article makes a number of useful points:

Almost all of the IBD medications (Anti-TNF, Vedolizumab, Ustekinumab, Tofacitinib, Ozanimod) should not be used in patients with untreated hepatitis B surface antigen positivity. Antiviral prophylaxis is recommended even patients with inactive disease (HBV DNA <2000 IU/mL/normal ALT) starting 2 weeks prior to immunosuppression up to 12 weeks after immunosuppression discontinuation.
Anti-TNF, Vedolizumab, and Ustekinumab can be safely used in patients with cirrhosis, tofacitinib requires a dose reduction, and ozanimod is NOT recommended
Autoimmune hepatitis may be triggered (rarely) by use of anti-TNFs; however, these agents have been uses off-label as a rescue therapy for AIH as well.
Anti-TNFs do not appear worsen liver function in PSC and may be associated with improvement in MASH (NASH)
Drug-induced liver injury (DILI) is common with anti-TNFs, often seen between the second and fifth doses. It is “generally transient and asymptomatic.” DILI may occur with ustekinumab, tofacitinib and ozanimod.
Tofacitinib may have a favorable effect on PSC. A retrospective study with 5 patients reported a 28% and 39% decrease respectively in total bilirubin and alkaline phosphatase within 6 months of starting therapy, A separate study with 42 patients showed a non-significant drop in alkaline phosphatase from 150 U/L to 132 U/L at 12 month followup.
The authors note that in patients with cirrhosis and posttransplantation, “vedolizumab and ustekinumab should be preferred due to their safer profile linked to infectious risk.”
“Patients with hepatobiliary disorders are often excluded from pivotal trials.” This contributes to a significant knowledge gap for patients with these comorbid conditions which are frequent in patients with IBD

My take: I don’t think I will be too popular if I hand out copies of this article to the kids I see later today –despite the useful advice. (This post was meant to be published on Halloween)

Related blog posts:

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.

How Much Ustekinumab (Stelara) Is Needed to Get a Good Response

Posted on October 25, 2023 by gutsandgrowth

K Chen et al. Inflamm Bowel Dis 2023; 29: 1499-1503. Serum Ustekinumab Concentrations Are Associated With Improved Outcomes With the Magnetic Resonance Index of Activity for Crohn’s Disease

This retrospective trial included thirty three patients with Crohn’s disease (CD) receiving maintenance ustekinumab (UST). The simplified Magnetic Resonance Index of Activity (sMARIA) and biomarkers were correlated with UST levels. The authors utilized a homologous mobility shift assay (HMSA) (Prometheus) for their UST levels.

Key findings:

With UST level greater or equal to 8.4, radiologic remission was seen in 63% compared to 21% in those with levels <8.4. Similarly, the absence of severe inflammation was seen in 78.9% of those with higher levels compared with only 36.8% in those with levels below 8.4.
Both findings were clinically-significant P=.01

With UST levels greater or equal to 6.1, FCP less than 50 was seen in 72.2% compared to only 12.5% in those with a level less than 6.1. P<.01

My take: This study show the need for higher levels of UST to achieve optimal outcomes. Levels of at least 8.4 appear to be a good target.

Related blog posts:

ChatGPT for Colonoscopy Questions Plus One

Posted on October 24, 2023 by gutsandgrowth

T-C Lee et al. Gastroenterol 2023; 165: 509-511. Open Access! ChatGPT Answers Common Patient Questions About Colonoscopy

In this study, ChatGPT answers to questions about colonoscopy were compared to publicly available webpages of 3 randomly selected hospitals from the top-20 list of the US News & World Report Best Hospitals for Gastroenterology and GI Surgery.

Methods: To objectively interpret the quality of ChatGPT-generated answers, 4 gastroenterologists (2 senior gastroenterologists and 2 fellows) rated 36 pairs of CQs and answers, randomly displayed, for the following quality indicators on a 7-point Likert scale: (1) ease of understanding, (2) scientific adequacy, and (3) satisfaction with the answer (Table 1) Raters were also requested to interpret whether the answers were AI generated or not.

Key findings:

ChatGPT answers were similar to non-AI answers, but had higher mean scores with regard to ease of understanding, scientific adequacy, and satisfaction.
The physician raters demonstrated only 48% accuracy in identifying ChatGPT generated answers

My take: This is yet another study, this time focused on gastroenterology, that show how physicians/patients may benefit from leveraging chatbots to improve communication.

Related blog posts:

Also this:

Study: PPIs Did Not Cause Dementia in Older Adults

Posted on October 23, 2023 by gutsandgrowth

Thanks to Ben Gold for encouraging me to review this article:

RS Mehta et al. Gastroenterol 2023; ; 165: 564-572. Open Access! Association of Proton Pump Inhibitor Use With Incident Dementia and Cognitive Decline in Older Adults: A Prospective Cohort Study

The authors used data from ASPirin in Reducing Events in the Elderly (ASPREE), a randomized prospective trial of aspirin in the United States and Australia, including 18,934 community-based adults ≥65 years of all races/ethnicities (enrollment 2010-2014). Final cognitive testing was done in 2017. Key Findings:

Baseline PPI use vs nonuse was not associated with incident dementia (multivariable hazard ratio, 0.88, cognitive impairment without dementia (multivariable hazard ratio, 1.00), or with changes in overall cognitive test scores over time.
Also, no associations were observed between H2RA use and all cognitive endpoints.

My take: ” These data provide reassurance about the safety of long-term use of PPIs among older adults.” PPIs are unlikely to have negative effects on cognition.

Related blog posts:

Thiopurines Efficacy in Children with Ulcerative Colitis

Posted on October 20, 2023 by gutsandgrowth

FA Hanna et al. JPGN 2023; 77: 505-511. Thiopurines Maintenance Therapy in Children With Ulcerative Colitis: A Multicenter Retrospective Study

In this retrospective study with 133 children (2008-2019), typical dosing of thiopurines: azathioprine 2-2.5 mg/kg/day and 6-mercaptopurine 1.5 mg/kg/day. Patients with previous or concomitant treatment with 5-ASA were allowed in the study. 62% (n=83) of the cohort had pancolitis. Key Findings:

Seventy-four patients (56%) had CS-free clinical remission at week 52 without rescue therapy
In the cohort in clinical remission, 67 and 51 patients had both CRP and calprotectin measurements at 1 year and end of follow-up. Sufficient biomarker response (CRP <1 mg/dL, calprotectin <250 mcg/g) was achieved by 44 (66%) and 44 (86%) at those two time points.
The likelihood of remaining free of rescue therapy among thiopurines-treated patients was 83%, 62%, 45%, and 37% at 1, 2, 3, and 4 years, respectively
8 of 133 (6%) stopped thiopurine therapy due to adverse effects

In their discussion, the authors make several points regarding efficacy and safety of thiopurines.

Many experts have advocated use of anti-TNF therapy agents for ulcerative colitis especially when 5-ASA medications are not effective.. This is based on higher efficacy and safety. With regard to safety, the authors note an “extremely low risk of lymphoma” citing a study from Israel in which children were followed until age of 30 years. No cases of hepatosplenic T-cell lymphoma were identified and the lymphoma rate was not statistically significant (O Atia et al. J Crohns Coliitis 2022; 16: 786-795 Open Access! Risk of Cancer in Paediatric onset Inflammatory Bowel Diseases: A Nation-wide Study From the epi-IIRN).
The authors note a recent review “rejected the hypothesis that initiation of biologic treatment later in the disease course correlates with lower response and remission rates in UC patients.”
Based on the efficacy and safety, the authors advocate for use of thiopurines “either early in the treatment course or as part of a de-escalation therapy…Thiopurines should be considered in the treatment of UC patients before the initiation of biologic drugs in most children.”

My take: In the U.S., it appears that thiopurine monotherapy, and even combination therapy, in pediatrics with IBD is used infrequently. Anti-TNF therapy with therapeutic drug monitoring is used routinely in patients if a 5-ASA is ineffective or not a good option. This article is a reminder that thiopurines are still a reasonable option. This would have been a good opportunity for a commentary in JPGN to add some context to this article regarding the role of these agents.

AGA guidelines for moderate-to-severe ulcerative colitis: “In adult outpatients with moderate to severe UC in remission, AGA makes no recommendation in favor of or against using biologic monotherapy or tofacitinib rather than thiopurine monotherapy for maintenance of remission.”

Related blog posts:

AGA Guidelines: Moderate to Severe Ulcerative Colitis (2020)
AGA Guidelines on the Management of Mild-to-Moderate Ulcerative Colitis (2019)
Guideline: Biomarker Use for Ulcerative Colitis (2023)
A Role for Thiopurine Therapy (2019) “Making New Friends Should Not Mean Losing Old Ones”
#NASPGHAN17 Is it time to stop using thiopurine therapy? (2017)
Support for Step-Up Therapy and Thiopurines (2017)
Optimal Dose of Thiopurine When Used for Combination Therapy

Approach to Fundic Gland Polyps and VCE for Polyposis Syndromes

Posted on October 19, 2023 by gutsandgrowth

AS Sami et al. JPGN 2023; 77: 439-441. Fundic Gland Polyps: Strategizing a Surveillance Framework for Children and Adolescents

Key points:

Most fundic gland polyps (FGPs) are small (0.1 to 1 cm) sessile polyps characterized histologically by cystic oxyntic glands with a mixture of parietal cells and chief cells.
Most FGPs are “sporadic” and associated with chronic PPI use. These are benign.
Syndromic FGPs are associated with familial adenomatous polyposis (FAP) and have a “0.6% lifetime risk of progressing to gastric carcinoma.” 73% of syndromic FGPs had low-grade dysplasia in one study.
Routine excision of FGPs is not recommended in the absence of high-risk features (see below)

In Figure 1, the authors outline an algorithm for surveillance:

Sporadic: If FGPs are thought to be sporadic and have no dysplasia, no follow-up is needed. If FGPs are thought to be sporadic, but have dysplasia, “consider diagnostic workup for syndromic FGP.” “Surveillance by EGD of sporadic FGPs with our without low-grade dysplasia is not routinely recommended, as progression to gastric cancer is rare… In patients with multiple FGPs (eg. carpeted polyposis), large (>1 cm) polyps, or the presence of high-grade dysplasia, FAP needs to be ruled via genetic testing and colonoscopy.”

Syndromic: If low risk FGP, then surveillance recommended beginning at 25 years of age. If high risk FGP, surveillance is recommended every 1-2 years. High-risk features include multiple FGPs (eg. carpeted polyposis), large (>1 cm) polyps, or the presence of high-grade dysplasia

C Phen, TM Attard. JPGN 2023; 77: 442-444. The Role of Capsule Endoscopy in the Management of Pediatric Hereditary Polyposis Syndromes

In this review, the authors recommend VCE for Peutz-Jeghers syndrome no later than 8 years of age; for constitutional mismatch repair deficiency, the authors recommend “consider VCE surveillance before age 10.”

Related blog posts:

Candle containers from Le Castellet, France

Expert Advice on Bloating, Belching and Distention

Posted on October 18, 2023 by gutsandgrowth

B Moshiree, D Drossman, A Shaukat. Gastroenterol 2023; 165: 791-800. Open Access! AGA Clinical Practice Update on Evaluation and Management of Belching, Abdominal Bloating, and Distention: Expert Review

Best Practice Advice:

#2: Treatment options for supragastric belching may include brain–gut behavioral therapies, either separately or in combination, such as cognitive behavioral therapy, diaphragmatic breathing, speech therapy, and central neuromodulators.
#6: Abdominal imaging and upper endoscopy should be ordered in patients with alarm features, recent worsening symptoms, or an abnormal physical examination only.
#7: Gastric emptying studies should not be ordered routinely for bloating and distention, but may be considered if nausea and vomiting are present. Whole gut motility and radiopaque transit studies should not be ordered unless other additional and treatment-refractory lower gastrointestinal symptoms exist to warrant testing for neuromyopathic disorders.
#10: Probiotics should not be used to treat abdominal bloating and distention.
#11: Central neuromodulators (eg, antidepressants) are used to treat bloating and abdominal distention by reducing visceral hypersensitivity, raising sensation threshold, and improving psychological comorbidities.

**Gastric belching**: tracing showing instead a distal to proximal increase in impedance with air clearing from the esophagus. *Arrows* indicate direction of air flow and high-resolution manometric view of gastric belching is shown with direction of air flow from stomach to upper esophagus seen (*orange arrow*)

Several points from review:

Belching can be from the esophagus or from the stomach.
Supragastric belching involves air clearing from the esophagus not from stomach and is frequently associated with anxiety.
Gastric belching is frequently associated with reflux and occurs after spontaneous transient relaxation of the lower esophageal sphincter.
Bloating is a subjective sensation of fullness, tightness or trapped gas. Food intolerances, bacterial overgrowth, and celiac disease need to be considered. If constipation is present, this should be treated.

My take: This is a good review with plenty of practical suggestions for management.

Related blog posts: