Category Archives: Uncategorized

Improving Mortality in Spain After Nationwide Access to Direct-Acting Antivirals

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J Politi et al. Hepatology 2022; 75: 1247-1256. Favorable impact in hepatitis C-related mortality following free access to direct-acting antivirals in Spain

Background: Free treatments for HCV infection with direct-acting antivirals (DAAs) became widespread in Spain in April 2015

Key findings:

  • After the intervention, there was a great acceleration of the downward mortality trend from HCV, whose annual percent change (APC) went from −3.2% (95% CI, −3.6% to −2.8%) to −18.4% (95% CI, −20.6% to −16.3%). There were also significant accelerations in the downward trends in mortality from HCC.

My take: More proof that DAAs can be life-saving.

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Can You Give Ustekinumab Subcutaneously After IV Reaction?

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J Sunny et al. JPGN Reports: May 2022 – Volume 3 – Issue 2 – p e205 Open Access: Hypersensitivity Reaction to Ustekinumab in Pediatric and Young Adult Inflammatory Bowel Disease Patients: A Case Series

This is a case series of six pediatric patients and young adults who developed hypersensitivity reactions during intravenous infusion with ustekinumab (UST).

Key findings:

  • Hypersensitivity reactions during intravenous (IV) induction dose of UST, ranging from mild allergic reactions to anaphylaxis, with no antibodies detected in the two who had testing
  • Reactions occurred 0-30 minutes after start of infusion
  • Management was with methylprednisolone in 5 of 6 patients, diphendyramine in 3 of 6, and epinephrine in 1. One patient was managed with IV diphenhydramine alone.
  • Four of six continued with UST subcutaneously without reactions. ***Change of formulation of UST from IV to subcutaneous was done in a controlled hospital-based setting. The other two 33% were switched to another biologic due to physician preference and were never exposed to the subcutaneous formulation
  • Although the exact pathogenesis of this infusion reaction remains unknown, it has been attributed to EDTA

My take: It appears that patients with UST hypersensitivity reactions can be changed to SC formulation. The authors recommend to trial a subcutaneous dose of UST in a controlled setting; in addition, they suggest testing with skin prick testing or specific IgE levels to EDTA done by allergy and immunology.

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Sandia Mountain, near Albuquerque

Amplified Gut Pain

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We could do a lot better than the following:

  • Irritable bowel syndrome (IBS)
  • Non-organic abdominal pain
  • Functional abdominal pain (FAP)
  • Visceral hyperalgesia

Everyday I see families and these terms create more work –not less.

DD Sherry (JAMA Pediatrics 2022; 176: 10-11. Amplified Pain—A Helpful Diagnosis) shares his views on chronic pain terminology with regard to rheumatology, but some of the same lessons should be applied to pediatric gastroenterology:

  • “The primary purpose of any diagnosis is to serve the patient. They want to know what they have, even if we, as scientists, do not know the cause or mechanism. For example, we have no idea why children have juvenile idiopathic arthritis and, even though it has the word idiopathic in it, giving the child and family this diagnosis is reassuring, allows them to stop looking for other reasons for their symptoms, lets them tell others what they have, and allows for therapy to begin.”
  • “Amplified pain, in essence, is when the body takes a signal and amplifies it to become symptomatic. The pain is disproportional, as is, frequently the degree of disability”
  • “Telling patients with amplified pain that their pain is chronic pain,… functional pain…is no help. Many of these children have already been told they are malingering”
  • “Using the term amplified pain is useful, understandable, and rational. These children are not exaggerating their pain complaint.”

My take: A term like amplified gut pain would be an improvement from what we have now. It could be introduced as another term for visceral hyperalgesia or as a childhood variant of IBS or FAP since it is not currently used in the literature.

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Bandelier National Monument, New Mexico

Endoscopic Assessment of Eosinophilic Gastritis

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I Hirano et al. Am J Gastroenterol 2022; 117: 413-423. Prospective Endoscopic Activity Assessment for Eosinophilic Gastritis in a Multisite Cohort Thanks to Ben Gold for this reference.

Methods: Endoscopic features were prospectively recorded (n=65) using a system specifically developed for EG, the EG Endoscopic Reference System (EG-REFS)

Key findings:

  • The most common endoscopic findings were erythema (72%), raised lesions (49%), erosions (46%), and granularity (35%); only 8% of patients with active histology (≥30 eosinophils/high-power field) exhibited no endoscopic findings
  • A strong correlation between EG-REFS scores and physician global assessment of endoscopy severity was demonstrated (Spearman r = 0.84, P < 0.0001)
  • EG-REFS severity was significantly correlated with active histology, defined by a threshold of ≥30 eosinophils/high-power field (P = 0.0002).

My take: This reference has a ton of terrific pictures (48 for Figure 1) which showcase the wide variety of endoscopic findings (unfortunately these are behind a paywall). Overall, the study lays the groundwork for scoring the severity of EG and for serial assessments.

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 Ristras are the strings of chile you see hanging along fences,
on patios and on portals all over New Mexico

Quality Forum: Understanding Food Allergy Testing (Part 2) & Atopic Dermatitis

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The Children’s Care Network (in Atlanta) has recently shared its Spring 2022 Clinical Quality Forum. Following is the link to the video recording. The poll during the live presentation is not active for the recording.

​Some of the slides that I think are most helpful ​are shown below (used with permission).  This 2nd part of content is from Dr. Brian Vickery which describes ​the relationship of atopic dermatitis to food allergy and best practices for prevention of food allergy:

ASCIA Handouts:

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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

Quality Forum: Understanding Food Allergy Testing (Part 1)

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The Children’s Care Network (in Atlanta) has recently shared its Spring 2022 Clinical Quality Forum. Following is the link to the video recording. The poll during the live presentation is not active for the recording.

Some of the slides that I think are most helpful are shown below (used with permission). The first part of content is from Dr. Gerry Lee which describes best practices for selecting patients for Food Allergen IgE testing:

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

Update on Esophageal Motility Disorders

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DA Patel et al. Gastroenterol 2022; 162: 1617-1634. Open Access: Esophageal Motility Disorders: Current Approach to Diagnostics and Therapeutics

Manometric classification of various esophageal motility disorders
based on CC v4.0. HRIM, high-resolution impedance manometry
Treatment options in patients with disorders of esophageal peristalsis after a careful endoscopy is performed to rule out a mechanical or mucosal disease (such as eosinophilic esophagitis
Impact of mucosal diseases, opioids, and connective tissue disease on esophageal motility. Figure shows presence of various secondary motility abnormalities, and the triangle indicates visual approximations of the prevalence of those motility abnormalities with each disease state. Most patients will have normal motility testing.

Eosinophilic Colitis Is Not a Typical EGID or IBD

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T Shoda et al. Gastroenterol 2022; 162: 1635-1642. Open Access: Evaluating Eosinophilic Colitis as a Unique Disease Using Colonic Molecular Profiles: A Multi-Site Study

Methods: Subjects with EoC (n = 27) and controls (normal [NL, n = 20], Crohn’s disease [CD, n = 14]) were enrolled across sites associated with the Consortium of Eosinophilic Gastrointestinal Disease Researchers. EoC was diagnosed as colonic eosinophilia (ascending ≥100, descending ≥85, sigmoid ≥65 eosinophils/high-power field) with related symptoms. Colon biopsies were subjected to RNA sequencing.

Key findings:

  • Among EoC and other EGIDs, there was minimal transcriptomic overlap and minimal evidence of a strong allergic type 2 immune response in EoC compared with other EGIDs
  • EoC transcriptome–based scores were reversible with disease remission and differentiated EoC from IBD, even after controlling for colonic eosinophil levels (P < .0001)

My take: The study indicates that eosinophilic colitis is likely unrelated to other eosinophilic GI disease and is likely unrelated to inflammatory bowel disease.

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Position Paper for Pediatric Breath Testing

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IJ Broekaert et al. JPGN 2022; 74: 123-127. Open access: An ESPGHAN Position Paper on the Use of Breath Testing in Paediatric Gastroenterology

This is a good article which provides pediatric dosing of breath testing agents and important considerations in methodology and interpretation. In addition, there are 22 graded recommendations (see below) –some may be surprising. For example, the breath testing is NOT recommended for diagnosis of H pylori but is recommended for determination of eradication therapy.

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Dupilumab: FDA Approval for Eosinophilic Esophagitis

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U.S. FDA (5/20/22): FDA Approves First Treatment for Eosinophilic Esophagitis, a Chronic Immune Disorder

“Today, the U.S. Food and Drug Administration approved Dupixent (dupilumab) to treat eosinophilic esophagitis (EoE) in adults and pediatric patients 12 years and older weighing at least 40 kilograms (which is about 88 pounds). Today’s action marks the first FDA approval of a treatment for EoE…”

“The efficacy and safety of Dupixent in EoE was studied in a randomized, double-blind, parallel-group, multicenter, placebo-controlled trial, that included two 24-week treatment periods (Part A and Part B)…In Part A of the trial, 60% of the 42 patients who received Dupixent achieved the pre-determined level of reduced eosinophils in the esophagus compared to 5% of the 39 patients who received a placebo…. In Part B, 59% of the 80 patients who received Dupixent achieved the pre-determined level of reduced eosinophils in the esophagus compared to 6% of the 79 patients who received a placebo”

My take: We will need to revise our patient handout and decide how best to position this very expensive therapy. Without insurance, Dupixent (2 pens of 300 mg/2 mL) costs $3,649.97 on GoodRx. For those with insurance, Dupixent has a manufacturer’s coupon (Dupixent MyWay).

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Sandia Mountain Tram