Category Archives: Uncategorized

Prospective Pediatric Study of the Persistence and Progression of Recurrent Abdominal Pain

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J Sjolund et al. Clin Gastroenterol Hepatol 2021; 19: 930-938. Prevalence and Progression of Recurrent Abdominal Pain, From Early Childhood to Adolescence

Using a prospective, population-based Swedish cohort (1994-1996) (BAMSE project), the authors analyzed data from 2455 children with complete follow-up evaluation at ages 1, 2, 12, and 16 years.

Key findings:

  • RAP was reported by 26.2% of children on at least 1 of 3 assessment points, of which 11.3% reported symptoms more than once
  • Children with RAP at 12 years had persistent symptoms at 16 years in 45% of cases and increased risks for RAP (relative risk, 2.2; 95% CI, 1.7–2.8), any AP-FGID (relative risk, 2.6; 95% CI, 1.9–3.6), and IBS (relative risk, 3.2; 95% CI, 2.0–5.1) at 16 years
  • Figure 3 summarizes the overlap of RAP at different time points:
  • **In early childhood (1-2 years of age), 149 (6%) had RAP per parental reports. Only 27 in this group, had RAP noted at 16 years of age which accounted for 7% of the total 16 year old cohort with RAP
  • **At 12 years of age, 98 (4%) had RAP. 44 (45%) of this group continued with pain at 16 years which accounted for 11% of the total 16 year old cohort with RAP

My take: Most children (84%) with RAP at 16 years of age did NOT report RAP at younger ages; however, in children with RAP at 12 years of age, 45% continued to have RAP at 16 years of age.

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ACG Guideline: Upper Gastrointestinal and Ulcer Bleeding

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Full Text: ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding (L Laine et al. Am J Gastroenter: 2021; 116 : 899-917.

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Gastric Emptying in Diabetes, Plus Two

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Briefly noted: RK Goyal. NEJM 2021; 384: 1742-1751. Gastric Emptying Abnormalities in Diabetes Mellitus

This article provides insight into the topic of gastric emptying with a focus on patients with diabetes. A few key points:

  • Gastric emptying affects glucose homeostasis in patients with diabetes; delayed gastric emptying in patients with type 2 diabetes could have beneficial effects in this regard.
  • Delayed gastric emptying occurs in 40-47% of adults with diabetes; rapid emptying occurs in 20-22%.
  • Upper GI symptoms do NOT correlate with gastric emptying. Prevalence of these symptoms is highest in those with normal gastric emptying (43-52% in those with normal emptying compared with 19-28% with delayed emptying, and 20-37% with rapid emptying)
  • “Functional dyspepsia-like symptoms in gastroparesis may arise not through motility changes but rather through the parallel effects of oxidative stress and inflammation on nocireceptors and on other afferents that produce the symptoms.”

My take: Knowing how quickly the stomach empties rarely helps management. In this review, Dr. Goyal states that “the effective treatment of symptoms in diabetic gastroparesis may be similar to the treatment of functional dyspepsia.”

Also, noted in same issue of NEJM:

TB Corcoran et al. NEJM 2021; 384: 1731-1741. Dexamethasone and Surgical-Site Infection Key finding: A single dose of dexamathosone (8 mg) did not increase the risk of surgical site infection; this is in contrast to long-term glucocorticoid therapy which is a risk factor for infection and wound dehiscence.

J Salwa et al. NEJM 2021; 384: 1684-6. Designing an Independent Public Health Agency. This article makes compelling arguments for separating health agencies from political influence. The FDA, the CDC, and HHS in the previous administration were pressured and undermined. In contrast, the Federal Reserve Board, which has 14 year terms that require ‘removal only for cause,’ was “reliably [able to] exert federal power because of its institutional features as an independent agency.”

From TikTok -twitter feed: The GI Bleeding Paradox (58 secs -humor) @DGlaucomflecken#Gastroenterology#GI#MedTwitter

Nutritional Therapy for IBD and Venous Thromboembolism in Pediatric Inflammatory Bowel Disease

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I was recently made aware of a useful website for IBD patients interested in nutritional therapy: Nutritional Therapy for IBD -Home Page

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EB Mitchell et al. Journal of Pediatric Gastroenterology and Nutrition. 72(5):742-747, May 2021.Venous Thromboembolism in Pediatric Inflammatory Bowel Disease: A Case-Control Study

Methods: A nested case-control study comparing hospitalized children with IBD diagnosed with VTE to those without VTE over a decade at a large referral center

Key findings:

  • Twenty-three cases were identified.
  • Central venous catheter (CVC) presence (odds ratio [OR] 77.9; 95% confidence interval [CI]: 6.9–880.6; P < 0.001) and steroid use (OR 12.7; 95% CI: 1.3–126.4; P = 0.012) were independent risk factors
  • Table 2 lists five severe cases which included interventions like balloon angioplasty, stent placement, surgical thrombectomy, and plasmapheresis/subtotal colectomy
  • The authors note that 1.3% of adolescents/children hospitalized with IBD had VTE

The authors note that ‘inherited prothrombotic disorders are not increased in IBD; “the pathogenesis of VTE in patients with IBD has been associated with increased activation of the coagulation cascade, impaired fibrinolysis, increased platelet count, and dysfunction of the endothelium.”

My take: The absolute risk of VTE is low in the pediatric population; presence of CVC and use of steroids are risk factors and require consideration of, at minimum, nonpharmacologic interventions.

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Esophageal Squamous Papilloma in Children Are Rare

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AM Tou, AO Al-Nimr. JPGN 2021; 72: 690-692. Esophageal Squamous Papilloma in Children: A Single-center Case

Key findings:

  • Of 12,459 children who had an EGD (2000-2014), 10 children (0.08%) were identified with an esophageal squamous papillom (ESP)a on biopsy. Ages ranged from 2 to 17 years.
  • All samples tested for HPV via FISH analysis were negative

The authors note that “surveillance is …largely considered unnecessary.”

My take: ESP is a rare benign lesion found incidentally in the pediatric population.

Image online from N Alkhouri et al. JPGN 46(3):237, March 2008.
Endoscopic Appearance of an Esophageal Squamous Papilloma in a Pediatric Patient

Persistently Abnormal Celiac Labs =High Likelihood of Celiac Disease

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CM Trovato et al JPGN 2021; 72: 712-717. Diagnostic Value of Persistently Low Positive TGA-IgA Titers in Symptomatic Children With Suspected Celiac Disease

This retrospective study provides insight into the predictive value of persistently abnormal celiac labs in symptomatic children.

Inclusion criteria:  not eligible for a non-biopsy diagnosis AND children with at least 2 TGA-IgA measurements, endomysial antibody (EMA) assessment and esophagogastroduodenoscopy with biopsies

Methods: Patients were classified in groups according to median TGA-IgA values: Group A (TGA-IgA>1 ≤ 5 × ULN; defined as “low-positive”), Group B (TGA-IgA > 5 < 10 × ULN; “moderate-positive”), and C (controls).

Key findings:

  • In group A, CD was diagnosed in 142/162 (87.7%)
  •  In group B, all 62 children (100%) received a CD diagnosis

My take: In individuals with mild elevation of celiac serology, it is reasonable to recheck prior to confirming with endoscopy. However, those with persistently abnormal values are very likely to have celiac disease.

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  • If TTG IgA at 1-fold ULN, then PPV 61%, NPV 98%, Sens 90%, Spec 90%
  • If TTG IgA at 2-fold ULN, then PPV 79%, NPV 97%, Sens 82%, Spec 96%
  • If TTG IgA at 5-fold ULN, then PPV 93%, NPV 94%, Sens 62%, Spec 99%
  • If TTG IgA at 7-fold ULN, then PPV 96%, NPV 91%, Sens 41%, Spec 100%
Near Hahn Woods, Atlanta

Polyethylene Glycol in the First Two Years of Life

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A recent retrospective study (D Roy et al. JPGN 2021; 72: 683-689. Full text: Utilisation and Safety of Polyethylene Glycol 3350 With Electrolytes in Children Under 2 Years) provides some reassurance that use of polyethylene glycol 3350 (PEG) (aka Miralax) was well-tolerated in children <2 years of age.

From an initial cohort of 20,861 from the Clinical Practice Research Datalink (CPRD) GOLD, the authors identified 13,235 patients with a constipation indication and 40 patients with fecal impaction indication for PEG.

Key finding:

  • The safety aspect of this study did not identify any signals of concern in the constipation cohort.
  • The mean duration of exposure, in the first treatment episode, was 88.9 days.
  • 9380 patients (70.9%) were aged between 12 and <24 months, with a further 3855 patients (29.1%) aged <12months. Also, PEG 3350+E was used in 477 patients (3.6%) who were <6 months of age

This type of retrospective study is less capable of detecting adverse events than a prospective study and is limited by how carefully the primary care provider elicits and documents them.

My take: This large study confirms the widespread usage of PEG in young children without apparent adverse reactions.

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Near Lullwater Park, Atlanta

Olive Oil Enemas for Constipation

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Briefly noted: A recent retrospective study (A Yokoi, N Kamata. J Pediatr Surg 2021; https://doi.org/10.1016/j.jpedsurg.2021.03.024 The usefulness of olive oil enema in children with severe chronic constipation) showed the potential utility of olive oil enemas for children (n=115) with constipation.

Treatment regimen: “A 1–2 ml/kg olive oil enema was given either alone or followed several hours later by a glycerin enema.”

Study population: “Forty-nine had functional constipation; 43 had anorectal malformation; 40 had Hirschsprung disease; 12 had spina bifida; and 10 had other maladies.”

  • Key finding: Olive oil enema was considered effective in treating fecal impaction in 77.6% of patients

My take: I don’t have any personal experience with olive oil but expect it would work similar to mineral oil.

Mural on beltline near Ansley Park

Trial by Diet Approach for Crohn’s Disease in Children

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RS Boneh et al. Clin Gastroenterol Hepato 2021; 19: 752-759. Dietary Therapies Induce Rapid Response and Remission in Pediatric Patients With Active Crohn’s Disease

The authors collected  data from a multicenter randomized trial of the CD exclusion diet (CDED) in children (mean age, 14.2 ± 2.7 y) with Crohn’s disease who were randomly assigned to groups given either exclusive enteral nutrition (EEN, n = 34) or the CDED with 50% (partial) enteral nutrition (PEN) (n = 39). 

The CDED has been discussed previously on this blog; it aims to avoid animal and saturated fat, milk fat, gluten, specific emulsifiers, taurine, red (reduced heme) and processed meat, and certain fibers from some fruits and vegetables. In addition to excluding patients who received competing therapies (eg. steroids, immunomodulators, and biologics), the authors excluded patients with isolated large bowel disease (L2).

Key findings:

  • At week 3 of the diet, 82% of patients in the CDED group and 85% of patients in the EEN group had a dietary response or remission. Median serum levels of C-reactive protein had decreased from 24 mg/L at baseline to 5.0 mg/L at week 3 (P < .001)
  • Among the 49 patients in remission at week 6, 46 patients (94%) had had a diet response or remission by week 3 and 81% were in clinical remission by week 3

The authors note that the rapid response to dietary therapy suggests a role for a ‘trial by diet’. As such, dietary therapy could be used as monotherapy, for patients failing other therapies, or as a bridge to biological therapy. The authors note that the exact reasons for response to dietary therapy are unsettled and could be “due to both foods excluded and foods enriched in the diet.” In addition, they note that diet appears to be a trigger for inflammation and that reintroduction of foods leads to rebound in inflammation (eg. higher calprotectin) and dysbiosis.

My take: This study shows that dietary therapy works quickly. In this small study, the effectiveness of combined CDED with 50% PEN was similar to EEN.

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