Category Archives: Pediatric Gastroenterology Intestinal Disorder

One More Problem with HIDA Scans

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A recent case study (A Adeyemi et al. J Pediatr 2020; 220: 245-8) provides information on 6 infants with a subsequent diagnosis of biliary atresia who had HIDA scans which reported excretion.

Methods: HIDA scans from 1992-2012 were reviewed from CHOP, this included 223 infants up to 4 months of age.

Key findings:

  • While there were six cases with HIDA scans that showed excretion into the bowel, none of these infants had truly normal HIDA scans.
  • 4 of the 6 patients had excretion qualified as slight, mild, or subtle and faint.
  • 5 of the 6 patients did not have the gallbladder visualized on HIDA.

Commentary:

  • HIDA scans are well-known to have a high sensitivity but a low specificity for biliary atresia (even with pretreatment choleretic agents). Liver biopsies have a higher diagnostic accuracy.
  • Since biliary atresia is a progressive disease, some excretion on HIDA does not exclude the diagnosis.  Though, age at HIDA was not a significant variable in this small series.

My takes:

  • Don’t rely too much on any test, including HIDA scans.  Equivocal findings need to be reported as such.
  • Fortunately, MMP-7 has emerged as another quick way with good (not perfect) specificity for biliary atresia.
  • Another related caveat is to look carefully at ultrasounds in this age group.  Often a small or retracted gallbladder is overlooked and could be an important clue to the diagnosis of biliary atresia.

Related blog posts:

Rhododendron Flowers (Spring 2020)

Does Stopping Cannabis Improve Cyclic Vomiting Syndrome?

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Cannabis use has been linked to hyperemesis. However, a recent cross-sectional study (T Venkatesan et al. Clin Gastroenterol Hepatol 2020; 18: 1082-90) that stopping cannabis rarely results in improvement in cyclic vomiting syndrome (CVS).

This study enrolled 140 patients who had CVS with a mean age of 37 years, all seen at a specialized clinic; 41% were current cannabis users and were classified as regular users (≥4/wk, n=30) or occasional users (<4/wk, n=26).

Key findings:

  • Only 1 of 56 (2%) reported that cannabis abstinence (for a month) resolved their CVS symptoms and 1 of 56 (2%) noted improvement with cannabis abstinence.
  • 27 of 56 (56%) reported that cannabis abstinence worsened their CVS symptoms; 19 (40%) reported no change with cannabis abstinence
  • Only 1 patient taking cannabis met Rome IV criteria for cannabinoid hyperemesis syndrome (CHS). This patient subsequently resumed cannabis with a higher proportion of CBD (less THC) without recurrence of CVS symptoms.  This provides some support to the idea that THC in cannabis is responsible for CHS.

My take: (borrowed from authors) “If a patient with CVS and chronic regular cannabis use is refractory to standard therapy, we recommend a period of abstinence of at least 6 months or a duration of time that exceeds at least 3 consecutive cycles.”

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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

 

How to Get Rid of the Placebo Effect in Inflammatory Bowel Disease Trials

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A recent study (M Duijvestein et al. Clin Gastroenterol Hepatol 2020; 18: 1121-32, editorial 1030-32) analyzed data from recent randomized, double-blind, placebo-controlled trials for Crohn’s disease (CD).  In these induction trials fro eldelumab, filgotinib, risankizumab, and ustekinumab, the authors found very low rates of placebo response (n=188 in placebo arms).

Key findings:

  • Based on endoscopic assessment of CD activity, response rate to placebo was 16.2%; response indicated >50% reduction in the simple endoscopic score for CD.
  • The rate of remission was 5.2%
  • Even lower rates of response were noted in those with elevated CRP at baseline (OR 0.93) and those with history of anti-TNF therapy (OR 0.31)

Commentary:

  • The key to lowering the placebo response are to use objective biologic markers rather than relying exclusively on clinical symptoms.
  • Central reading of endoscopic endpoints also is thought to minimize placebo effect
  • The editorial notes that the use of placebo in clinical trials “must be justified by the importance of the additional scientific value gained, and placebo should be used in trials only if there is genuine equipoise between the active treatment and placebo.”
  • “Because of ethical questions concerning placebo and the emergence of head-to-head trials, placebo arms may disappear from future IBD trials.”

My take: In reality, very few individuals with CD improve without adequate treatment.  Use of objective criteria is crucial to finding out what really works, both in clinical trials and in clinical practice.

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Is It Safe for Me to Go to Work?

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Just for fun —YouTube (~3 minute video): The Swish Machine: 70 Step Basketball Trickshot (Rube Goldberg Machine)

Full text —MR Larochelle. DOI: 10.1056/NEJMp2013413. NEJM: Is It Safe for Me to Go to Work?

An excerpt:

I believe that a strategy to protect at-risk workers needs at least three components: a framework for counseling patients about the risks posed by continuing to work, urgent policy changes to ensure financial protections for people who are kept out of work, and a data-driven plan for safe reentry into the workforce…

The Occupational Safety and Health Administration has published guidance and proposed a scheme for classifying the risk of SARS-CoV-2 infection as high, medium, or low based on potential contact with persons who may or do have the virus (www.osha.gov/Publications/OSHA3990.pdf. opens in new tab). Low-, medium-, and high-risk categories of individual risk of death from Covid-19 are based on age and the presence of high-risk chronic conditions identified by the CDC…

As states move to reopen their economies, millions of nonessential employees will join essential employees in putting themselves at risk for contracting SARS-CoV-2 at work. Physicians should engage patients in individualized risk assessments. Our society has the moral imperative and means to provide vulnerable employees a financial safety net until we can better ensure their workplace safety.

Related blog post: @Atul_Gawande: How to Reopen

Prevalence of Rome IV Functional Bowel Disorders in Adults (US, UK, Canada) & Largest Study to Date on Hydroxychloroquine for COVId-19

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OS Palsson et al. Gastoenterol 2020; 158: 1262-73.  The authors note that the switch from Rome III to Rome IV criteria reduces the prevalence of IBS by half, but increases the prevalence of functional constipation and functional diarrhea.

Full text PDF: Prevalence of Rome IV Functional Bowel Disorders Among Adults in the United States, Canada, and the United Kingdom

Abstract

BACKGROUND & AIMS:

Little is known about the population prevalence or demographic distributions of Rome IV functional bowel disorders (FBDs) or their effects on quality of life. We examined these in a multinational survey.

METHODS:

We analyzed data from a population-based [online] survey of adults in the United States, Canada, and United Kingdom (5931 valid responders; 49.2% female; mean age, 47.4 years; range, 18-92 years). The survey included the Rome IV Diagnostic Questionnaire, Rome III irritable bowel syndrome (IBS) and constipation questions, and the SF-8 quality of life questionnaire.

RESULTS:

The prevalence values of census-adjusted Rome IV FBDs were similar among the 3 countries; ranges were: 4.4%-4.8% for IBS, 7.9%-8.6% for functional constipation, 3.6%-5.3% for functional diarrhea, 2.0%-3.9% for functional bloating or distention, 1.1%-1.9% for opioid-induced constipation, 7.5%-10.0% for unspecified FBDs, and 28.6%-31.7% for any Rome IV FBD. FBDs were less common in older individuals, and all except functional diarrhea were more common in women. IBS was only half as prevalent by Rome IV as by Rome III criteria (4.6% vs 9.0% overall), primarily due to higher Rome IV minimum pain frequency. Functional diarrhea and functional constipation were more prevalent by Rome IV than Rome III criteria. Subjects with FBD had significant reductions in quality of life and reported more gastrointestinal doctor consultations than other subjects.

CONCLUSIONS:

More than 1 in 4 adults in the general population meet the Rome IV criteria for FBDs. These disorders affect quality of life and increase use of gastrointestinal health care. The switch from Rome III to Rome IV criteria reduces the prevalence of IBS by half, but increases the prevalence of functional constipation and functional diarrhea.

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From @EricTopol: Just published @TheLancet The largest study of hydroxychloroquine shows a significant increase in death (~35%) and >2-fold increase of serious heart arrhythmias. ~96,000 patients, ~15,000 on HCQ or CQ from 671 hospitals, 6 continents.

More Jokes:

Early Treatment with Anti-TNF Agents and Development of Perianal Fistulas

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AAM Singer, DA Bloom, J Adler. Clin Gastroenterol Hepatol 2020; In Press: Factors Associated With Development of Perianal Fistulas in Pediatric Patients With Crohn’s Disease

Also, related article:

Full Text: 2019 Jan 1;25(1):1-13. doi: 10.1093/ibd/izy247. Clinical Practice Guideline for the Medical Management of Perianal Fistulizing Crohn’s Disease: The Toronto Consensus.

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.

Briefly Noted: Shwachman-Diamond

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S Cesaro et al. J Pediatr 2020; 219: 196-201.  This prospective study with 121 patients provides long-term survival information regarding Shwachman-Diamond syndrome which is characterized by exocrine pancreatic insufficiency, hematologic alterations, skeletal abnormalities and sometimes liver disease. Key findings:

  • Initial hematologic parameters included severe neutropenia in 25.8%  , thrombocytopenia in 25.5%, and anemia in 4.6%; cumulative incidence of these abnormalities at 30 years of age were 59.9%, 66.8%, and 20.2% respectively
  • 20-year cumulative incidence of myelodysplasia/leukemia was 9.8% and of bone marrow failure/severe cytopenia was 9.9%.
  • 15 (12.4%) underwent stem cell transplantation
  • 15 (12.4%) died with probability of survival at 10 yrs: 95.7% and at 20 yrs 87.4%

My take: This study shows the hematologic morbidities associated with Shwachman-Diamond –important information for the pediatric gastroenterologist following these children for pancreatic insufficiency or liver-related abnormalities.

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Also, a previous post (Do Button Battery Guidelines Need to be Revised?) reviewed an abstract suggesting that gastric button batteries could result in mucosal injury.  This has now been published: (Gastrointestinal Endoscopy, DOI: https://doi.org/10.1016/j.gie.2020.04.037 In press) Gastric injury secondary to button battery ingestions: a retrospective multicenter review

Curbside humor: How do you make a tissue dance?  Put a little boogie in it.

Island Ford National Recreation Area/Chattahoochee River

 

New 2020 Eosinophilic Esophagitis Guidelines

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Full text (I Hirano et al. Gastroenterol 2020; 158: 1776-86): AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters Clinical Guidelines for the Management of Eosinophilic Esophagitis

Full text: PDF

This guideline was developed through a collaboration between AGA and the Joint Task Force for Allergy-Immunology Practice Parameters, which comprises the American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma & Immunology. This guideline is jointly published in Gastroenterology and Annals of Allergy, Asthma and Immunology.

Technical review article (MA Rank et al. Gastroenterol 2020; 158: 1789-1810): Technical Review on the Management of Eosinophilic Esophagitis: A Report From the AGA Institute and the Joint Task Force on Allergy-Immunology Practice Parameters

 

Link: Clinical Decision Support Tool

Link: Treatment of EoE Spotlight Poster

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