4 patients with Crohn’s disease had loss of response.
9% of patients were switched back to IV vedolizumab due to adverse events or fear of needles.
Median clinical and biochemical disease activity remained stable after the switch. Median vedolizumab serum concentrations increased from 19 μg/ml at the time of the switch to 31 μg/ml 12 weeks after the switch (p < 0.005).
HC Kaplan et al. Am J Gastroenterol 2022 Jun 1;117(6):902-917. Open access: Personalized Research on Diet in Ulcerative Colitis and Crohn’s Disease: A Series of N-of-1 Diet Trials. In this study, 21 patients (completed trial) were randomized to 1 of 2 sequences of 4 alternating 8-week SCD (specific carbohydrate diet) and MSCD (modified specific carbohydrate diet) periods.
Key findings: “SCD and MSCD did not consistently improve symptoms or inflammation.” “Some individuals had improvement in symptoms and fecal calprotectin compared with their UD, whereas others did not.” The authors note that it took 18 months to recruit 54 patients for this study across 19 research sites.
Black adult patients were significantly less likely than White patients to have a diagnosis of CD (odds ratio [OR], 0.53) or UC (OR, 0.41). Pediatric Black patients were also less likely to have a diagnosis of CD (OR, 0.41) or UC (OR, 0.38)
Adult Hispanic patients were less likely to have a diagnosis of CD (OR, 0.33) or UC (OR, 0.45) compared with non-Hispanic patients. Similarly, pediatric Hispanic patients were less likely to have a diagnosis of CD (OR, 0.34) or UC (OR, 0.50).
Thus, these data suggest that CD and UC are modestly less prevalent among patients of non-White races and Hispanic ethnicity
A recent Bowel Sounds had some very useful insight into gastroparesis/dyspepsia. This bowel sounds was particularly interesting with regard to gastric electrical stimulation (very effective in highly selected group) and pyloric botox. It also reviewed many of the difficulties in diagnosis/overlap with dyspepsia.
Lu PL, Di Lorenzo C. Gastroparesis in the Pediatric Patient: Children are Not Little Adults. Gastrointest Disord. 2020, 2(2), 86-95
Lu PL, Moore-Clingenpeel M, et al. The rising cost of hospital care for children with gastroparesis: 2004-2013. Neurogastroenterol Motil. 2016 Nov;28(11):1698-1704.
Lu PL, Teich S, et al. Improvement of quality of life and symptoms after gastric electrical stimulation in children with functional dyspepsia. Neurogastroenterol Motil. 2013 Jul;25(7):567-e456.
Orsagh-Yentis DK, Ryan K, et al. Gastric electrical stimulation improves symptoms and need for supplemental nutrition in children with severe nausea and vomiting: A ten-year experience. Neurogastroenterol Motil. 2021 Sep;33(9):e14199.
Neuromodulator Algorithm for Adults with Disorders of Gut-Brain Interaction from @Liane428:
” I tend to refrain from ordering gastric emptying studies in patients with nausea unless vomiting hours after eating occurs.” According to the article, this is mainly due to the overlap symptoms of gastroparesis and functional dyspepsia, the suboptimal reliability of testing, and the uncertain value of testing in targeting therapy.
“Much like in most other DGBI, diagnostic tests in patients with chronic nausea should only be indicated in the presence of other alarm signs or features (weight loss, severe pain, bilious vomiting, etc.) (29). Upper endoscopies are particularly unhelpful with 98% reported to be normal in patient with nausea as the predominant symptom”
“Most beneficial treatment is hypnotherapy.” Cognitive behavioral therapy is likely helpful.
Medications that may be useful: cryproheptadine, STW5 (an herbal supplement), scopolamine patch, and erythromycin (when there is gastroparesis); “use of psychotropic agents such as amitriptyline, buspirone, and mirtazapine (which decrease visceral hyperalgesia, improve accommodation or accelerate gastric emptying may be justified in selected cases.” There is little evidence that classical antiemetics such as ondansetron are beneficial for functional nausea.
Also consider wrist acupuncture &/or commercially available devices based on the same principle, endoscopic injection of botulinum toxin in the pylorus; implantation of a gastric pacemaker improves drug-refractory nausea. Treatment of anxiety and depression, if present, is also beneficial.
My take: This is a useful review on a tough disorder to manage.
This article found that hypnotherapy was more effective than standard medical therapy during the first 6 months and similar subsequently in children with functional nausea. Standard medical therapy was a progression of treatment:
In an ancillary study of the Vitamin D and Omega-3 Trial (VITAL), the investigators tested whether supplemental vitamin D3 would result in a lower risk of fractures than placebo. Design: VITAL was a two-by-two factorial, randomized, controlled trial with 25,871 participants with a median followup of 5.3 years.
Supplemental vitamin D3, as compared with placebo, did not have a significant effect on total fractures (hazard ratio, 0.98), nonvertebral fractures (hazard ratio, 0.97), or hip fractures (hazard ratio, 1.01).
From the editorial:
This study reinforces a recent trial which found that Vitamin D supplementation did not significantly improve bone mineral density/structure with high-resolution CT.
“There is no justification for measuring 25-hydroxyvitamin D in the general population or treating to a target serum level.” Exceptions may include some patients at high-risk for deficiency like persons living in residential settings with little sunlight exposure and those with malabsorptive conditions (eg. celiac disease, cholestatic liver disease).
“Providers should stop screening for 25-hydroxyvitamin D levels or recommending vitamin D supplements and people should stop taking vitamin D supplements to prevent major diseases or extend life.”
This report showed a significant temporal association between esophageal air events (EAEs) and hiccups using impedance-pH monitoring (I-pHM). EAEs include air swallows, gastric belching, and supragastric belching
This article reviews physiology of hiccups:
“Hiccups are physiologically normal but can become pathological when they occur with increasing regularity or for extended periods of time (1). The occurrence of hiccups is mediated through a reflex arc that consists of 3 basic branches: (1) afferent/sensory limb involving vagal, phrenic, and sympathetic nerves; (2) medulla and possibly the cervical spine (8) where central processing occurs; and (3) efferent/motor limb involving motor fibers of phrenic nerves and accessory nerves that innervate the diaphragm and intercostal muscles, respectively (1,9). A hiccup may be caused by any disturbance that triggers one of these branches (1).”
Understanding reasons for hiccups may help with treatment:
“We initially tried treating this patient’s hiccups with acid suppression. When symptoms persisted despite H2 blocker, PPI, and cyproheptadine therapy, I-pHM confirmed minimal GER and allowed us to focus instead on other treatments: behavioral techniques, diaphragmatic breathing, and baclofen.”
My take: It is nice to see a correlation between hiccups and physiology with I-pHM. In some patients, baclofen along with diaphragmatic breathing may be a consideration prior to definitive testing.
Key point: This study examines the marketing of unhealthy food and non-alcoholic beverages on TikTok. Videos posted by top food brands frequently feature branding, product images, engagement and celebrities/influencers. These videos reach billions of views.
Design: This was a multicenter, randomized, double-blind, placebo-controlled withdrawal study of infliximab in patients (n=115) with Crohn’s disease who were in clinical, biochemical, and endoscopic remission after standard infliximab maintenance therapy for at least 1 year. Patients were randomly assigned 1:1 to continue infliximab therapy or to receive matching placebo for 48 weeks.
At the end of the trial at week 48, relapse-free survival was 100% in the infliximab-continuation group and 51% in the infliximab-discontinuation group
My take (borrowed from authors): Discontinuation of infliximab for patients with Crohn’s disease receiving long-term infliximab therapy and in clinical, biochemical, and endoscopic remission leads to a considerable risk of relapse
“Catheter occlusion, which occurs when the powder contacts blood or fluid within the catheter, is the main technical obstacle to successful powder delivery. Here is a cost-effective technique that overcomes this issue via the addition of a protective bone wax plug and stopcock (VideoGIE. 2021;6(9):387-389).”
“To set up, a tiny piece of bone wax is shaped into a 1-mm bead and applied to the tip of the 7 or 10 Fr delivery catheter (Figure 1). The catheter is then affixed to the Luer-lock end of a 3-way stopcock. The activated hemostatic powder device and an air-filled syringe are attached to the remaining ends of the stopcock. The stopcock initially is turned to oppose the device (Figure 2)…To fire without drying the working channel or air flushing the catheter, pass the bone wax–tipped catheter down the channel. The catheter tip is protected from moisture, and fluid can be suctioned, especially when using the 7 Fr catheter in a therapeutic gastroscope. When ready to fire, the bone wax plug is ejected with an air flush (Figure 3), the stopcock is turned to oppose the syringe (Figure 4), and the hemostatic powder is deployed.”
My take: If you follow the hemospray instructions carefully, this minimizes issues with catheter occlusion. This clever technique is likely to further eliminate this problem.
For thickeners, Dr. Rosen recommends Gelmix for infants with reflux who are breastfed or receiving amino acid formulas. Cereal does not work for breastmilk or amino acid formulas.
For infants, acid suppression, especially proton pump inhibitors, have not been shown to be effective but could contribute to a higher risk of allergies, infections and possibly bone complications.
The podcast reviewed the rationale for a time-limited trial of hydrolysates for infants with reflux symptoms due to the overlap of symptoms between reflux and MSPI. However, if it is not effective in several weeks, then it should be stopped.
Dr. Rosen does use “spit-up formulas” which can help reduce reflux symptoms and potentially help with swallow dysfunction. These are particularly well-suited for NG tubes as additional cereal in other formulas result in clogged NG tubes.
Several new technologies have helped understand esophageal physiology much better including pH-impedance, high-resolution manometry and FLIP device. PH-impedance can help better categorize reflux symptoms into non-erosive reflux disease, reflux hypersensitivity, and functional heartburn; however, this test is used fairly infrequently at Dr. Rosen’s center as the test is burdensome.
For older children/teenagers with functional heartburn symptoms, Dr. Rosen most frequent neuromodulator is gabapentin, which may alleviate coughing as well.
Fundoplications have fallen out of favor and are undertaken much less frequently. The use of blenderized formulas or gastrojejunostomy tubes are often used to manage reflux symptoms in patients with neurologic impairment.
Other treatments like prucalopride are emerging but quite limited in use in part due to lack of insurance coverage/cost.
Red throat on ENT exam is not specific for reflux
Aspiration, not reflux, is a common reason for infants who have coughing or BRUEs
In infants, nonacid reflux is the main issue, not acid reflux
My take: If you like one of these podcasts, is it proper to say “I liked hearing your bowel sounds?”
This large retrospective cohort study (2006-2017) identified 960 infants with in utero biologic medicine exposures (most commonly etanercept, anakinra, adalimumab, and infliximab) among 582,759 infants. Key findings:
Receipt of live-attenuated rotavirus vaccine in their first year or measles vaccine during their first 24 months were not at increased risk of prespecified adverse events compared to unexposed children
There was not a significant difference in diarrhea, bloody stools, intussusception, vomiting, encephalitis, myelitis, hepatitis, ataxia, or fevers
Receipt of the recommended number of doses of rotavirus vaccines in the first year of life was lower among biologic-exposed than among unexposed children (81.00% vs 85.20%, adjusted OR = 0.74)
Examples of guideline recommendations with regard to live-virus vaccination:
In their discussion, the authors note that this “provide some reassurance to parents and pediatricians regarding live-attenuated vaccines for children exposed to BRM [biologics] in utero. Professional societies may want to consider reevaluating their live-attenuated vaccines recommendations for these children as new safety data accumulates.”
My take: There are clearly theoretical concerns about biologic-exposures of infants in utero since some are actively transported across the placenta barrier and can remain in infants for up to 12 months after birth. However, this study could not identify significant adverse effects in exposed infants.