Category Archives: Uncategorized

How Gastrostomy Tube Placement Influences Gastroesophageal Reflux

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A recent prospective observational study (M Aumar et al. J Pediatr 2018; 197: 116-20) examined the effect of percutaneous gastrostomy (PEG) tube placement on gastroesophageal reflux disease (GERD) over a 13 year period. This study included 326 patients, 56% who had neurologic impairment and had a median follow-up of 3.5 years (and in some cases follow-up to 15 years). GERD was defined as gastroesophageal reflux causing troublesome symptoms and/or complications. Routine pH studies or impedance were not performed.

Key findings:

  • GERD was present in 242 of 326 patients at baseline (74%).  GERD appeared in 11% of patients after PEG and was aggravated in 25% with preexisting GERD.
  • Factors associated with worsening GERD were neurologic impairment and preexisting GERD.
  • 53 patients (16%) required anti-reflux surgery with 22 (6%) in the year following PEG. The only factor identified with the need for surgery was neurologic impairment.
  • At last followup, PEG remained in place in 133 children (41%), and had been removed in 99 (30%).  94 children (29%) were deceased, including 2 from an early procedure-related complication.  In those who were deceased, the vast majority occurred related to evolution or complication of their underlying disease.

The authors note that studies have shown that PEG increases GERD, but “the majority of these studies were of low methodologic quality.”

My take: Routine antireflux surgery at the time of PEG placement is NOT needed in the majority of patients, even in those with baseline GERD.  Less than 20% of patients with GERD required antireflux surgery.

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How Often Should an Endoscopy Be Normal?

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An interesting retrospective study (S Wang et al. JPGN 2018; 66: 876-81) looks at a total of 218 endoscopies in 164 children and examines findings in relation to gastrointestinal symptoms.  The results focus mainly on upper endoscopy as there were only 20 who had isolated colonoscopy.

Key findings.

  • 164 of 612 (26.8%) of all new patients had an endoscopy
  • Among upper endoscopy, 72% were histologically normal, and 56% were macroscopically normal.  The authors suspect those with abnormal macroscopic appearance and normal histology were mainly errors in interpretation.
  • In those with isolated colonoscopy, 25% were histologically and macroscopically abnormal; thus, complete concordance among the 20 cases.
  • In those with combined procedures, the likelihood of abnormalities was higher at 53% for both histology and macroscopically being abnormal.  This higher rate was driven mainly by the increased suspicion and diagnosis of inflammatory bowel disease in this subset of 74 patients.
  • Overall, 49% of all first diagnostic endoscopies were completely normal, though 65% were histologically normal.
  • For upper endoscopy, in those who had performance for isolated abdominal pain, the histologic yield was 11%.  It was also 11% for reflux.  The symptom with highest yield was vomiting, yet even for this, the findings were normal in about 80%.
  • For colonoscopy, rectal bleeding had the highest yield, but 72% were normal in this small cohort, indicating that a trial of conservative management may be appropriate.

An important point in the discussion.  The authors take an exception to the idea that normal findings are reassuring.  “When procedures are performed despite the expectation of normality this has not been shown to lead to better clinical outcomes of patients…abdominal pain was unaffected by whether or not the patient had undergone endoscopy>”

My take: I agree with the authors that the histologic findings are more likely significant than macroscopic findings in the majority of patients.  However, it is worth noting that mild histologic findings are of dubious importance in many cases.  Ultimately, identifying strategies to maximize diagnostic yield is needed to provide more cost-effective care and minimize the risks of unnecessary procedures.

 

The Impact of Maternal Antibiotics on Necrotizing Enterocolitis and Death in Neonates

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A recent study (BD Reed et al. J Pediatr 2018; 197: 97-103) showed that prenatal antibiotic exposure was associated with lower rates of necrotizing enterocolitis (NEC) or death.

In this secondary analysis of a progressive study with 580 infants (<32 weeks) that were cared for in Level III neonatal intensive care units, the authors examined the outcomes of the neonates in relation to whether their mothers had prenatal antibiotics within 72 hours of delivery.

Key findings:

  • Two-thirds of mothers received antibiotics w/in 72 hrs of birth, mainly ampicillin (37%) and azithormycin (26.4%).  Most (~60%) of the mothers who received antibiotics received more than 1 antibiotic.
  • In this cohort, NEC occurred in 7.5%, late onset sepsis (LOS) in 11.1%, and death in 9.6%.  The combined outcome of any of these events occurred in 21.3% of study infants.
  • Prenatal antibiotics were associated with a reduced risk of NEC (OR 0.28, CI 0.14-0.56), reduced risk of death (OR 0.29, CI 0.14-0.60) but not LOS (OR 1.59, CI 0.84-2.99).  Thus, the first two outcomes were within the confidence limits but not LOS.

The authors indicate that their initial hypothesis was that maternal antimicrobials (w/in 72 hours of birth) would increase the risk of NEC but in fact provided a 3-fold protection and reduced the risk of death.  The effects presumably would be mediated by changes in the infant microbiome related to infant’s exposure to microbial environment at birth and/or transplacental passage of antibiotics.  The authors note that their study did not consider mothers to be in the exposure to antibiotics group if their only exposure was antibiotics at the time of cesarean section due to limited time to effect neonate.  They did review this group and noted that if they were included in the exposure group that it would not have significantly changed the findings.

My take: This  intriguing finding that NEC and death occurred less often in infant’s whose mothers received antibiotics prior to delivery needs further study as does the long-term effect.

 

How Does Splenda Affect the Gut Microbiota?

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“You should never assume. You know what happens when you assume. You make an ass out of you and me because that’s how it’s spelled.”

–Attributed to multiple individuals (but I heard this first when I watched Bad News Bears as a kid)

The increasing frequency of many conditions like inflammatory bowel disease cannot be explained by our genetics.  The search for environmental triggers are ongoing.  Broadly, the main suspects are dietary, antimicrobials, and pollutants. (Related blog post: Nutrition Week (Day 7) Connecting Epidemiology and Diet in Inflammatory Bowel Disease)

The latest concern is now Splenda:

“The Artificial Sweetener Splenda Promotes Gut Proteobacteria, Dysbiosis, and Myeloperoxidasse Reactivity in Crohn’s Disease-Like Ileitis” A Rodriguez-Palacios et al. Inflamm Bowel Dis 2018; 24: 1005-20.  Editorial 1055-6 by B Chassaing and AT Gewirtz.

This highly technical study involved research in ileitis-prone SAMP mice and includes a huge amount of data and cool figures.

The authors note in their discussion: “The term ‘Western diets’ implies a proven shift of the microbiota that enhances the susceptibility to adherent-invasive E coli infections and intestinal inflammation in mice.  In this study, we report similar findings due solely to the administration of a minor component of the diet.”

Some of the key points in the editorial:

  • IBD has multigenic influences and “results from a general breakdown in the normally mutually-beneficial relationship between the intestine and the complex microbial community it harbors.”
  • “New findings …that Splenda promotes microbiota dysbiosis in mice and exacerbates a hallmark of inflammation in ileitis-prone SAMP mice suggest that consumption of this synthetic sweetener may be a specific factor that contributes to development of IBD in persons genetically prone to this disorder.”
  • Splenda has two main components: sucralose (sweetener) and maltodextrin (filler)
  • Splenda did not “impact inflammatory markers in control mice, but rather increased such parameters in SAMP mice.”
  • Splenda changed the microbiota in both control mice and SAMP mice, “particularly enrichment of gamma Proteobacteria, which are broadly associated with gut inflammatory diseases.”
  • “Splenda may be relatively safe for the majority of the population but still represents a serious risk factor for those prone to developing IBD or other chronic inflammatory diseases.”
  • Substances like sucralose which are primarily excreted in the feces (nonabsorbed) have generally been viewed as harmless.  “Appreciation of the pivotal role of the microbiota in health questions the latter assumption.”

My take: I think the influences on the microbiota are difficult to tease out.  Thus, this study (in mice) indicates —don’t assume that nonabsorbed agents are harmless

Why Did the Young Woman’s Heartburn Keep Getting Worse?

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Mystery NY Times Case: Why Did the Young Woman’s Heartburn Keep Getting Worse?

An excerpt:

The radiologist who read the scan made an interesting observation. In each of the three visits to the E.R., the patient’s blood had been tested. All three tests showed an elevated white-blood-cell count. That could suggest an infection — but in her tests a quarter of those white blood cells were a cell type known as eosinophils, which normally make up only a tiny fraction of the white blood cells in the circulation. ..

When the radiologist saw the elevated level of eosinophils, however, he recalled an unusual and relatively new disorder known as eosinophilic gastroenteritis (EGE). He added this rarity to the list of possible causes of the patient’s abnormal CT findings on his report…

EGE is thought to be an unusual type of allergic reaction to foods. Food exposure triggers the recruitment of eosinophils to the gut, but once they have a toehold, repeated exposure isn’t necessary to keep them there. The disorder was first described in a series of patients in the United States in 1993 but since then has been found to occur throughout the developed world. Because it’s a relatively new disease, and because our understanding of allergy is still emerging, it’s not well understood. As recognition of the disorder expands, so, too, do the number of cases. Patients are usually started on an elimination diet and given steroids to further suppress the immune system. An elimination diet — one in which the foods most frequently linked to allergic reactions, like milk, eggs and wheat, are not consumed — has been shown to be helpful up to 90 percent of the time.

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Low-Value Care: IBD Serologies for Diagnosis of IBD

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A recent high-value care series (MD Long, BE Sands. Clin Gastroenterol Hepatol 2018; 16: 618-20) explains why “clinicians should not use IBD serologies as a test to diagnose inflammatory bowel disease.”

Here are the key points:

  • “Benoir et demonstrated that a 7-marker serology panel had a lower predictive value than routine laboratory tests in diagnosis of IBD among symptomatic pediatric patients.”
  • “Studies on the accuracy of these serologies for diagnosis included populations with a high prevalence of IBD (42%-62%), rather than the low-prevalence populations in primary care settings” (or even in for routine GI office visits)…”When the disease is rare, a greater proportion of the positive tests represent false positives and the PPV [positive predictive value] is low.”
  • The authors also recommend against using serologies to predict a more aggressive course because “no data exist that modifications based on these serologies improve outcomes.”

My take: When I highlight this article, there is an element of confirmational bias as I have held a dim view of their value for a long time. While there is some academic interest in IBD serology results, to me, it is a disturbing trend to see patients with nonspecific abdominal pain referred who have already had these serological markers.

Low Fiber Diet During Bowel Prep

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A recent prospective, randomized trial (A Mytyk et al. JPGN 2018; 66: 720-24) compared a low fiber diet with a clear liquid diet during a polyethyylene glycol prep prior to colonoscopy. N=184, Median age 15 yrs (range 6-18 yrs).

Low fiber diet included milk, dairy products, some soups, bread and rolls, sandwiches, meat, fish, eggs, pasta, and honey.

Children in both groups were asked to fast for a minimum of 6 hours prior to colonoscopy and their bowel prep was assessed with the Boston Bowel Preparation Scale (BBPS). Bowel prep consisted of PEG 4000 with electrolytes dosed at 66 mL/kg to max of 4 liters.

Key findings:

  • There was no significant difference in BBPS between the two groups
  • Overall, 95.4% of patients had good bowel cleanness (BBPS ≥5)

My take: This study indicates that with a good volume of bowel prep, a less-rigorous diet change may be effective for a cleanout.

Disclaimer: These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.

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