Dreaded Nausea (2017)

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This post provides followup to a previous post: Dreaded Nausea.

A recent study (AC Russell, AL Stone, LS Walker, Clin Gastroenterol Hepatol 2017; 15: 706-11) provides even more reasons to dread nausea.

This prospective study of 871 children with functional abdominal pain examined the comorbidity of nausea.  Followup data were collected from 392 patients at median of 8.7 years later.

Key findings:

  • At baseline, 44.8% of patients reported nausea. This group reported worse abdominal pain, somatic symptoms and depression than those without nausea.
  • At followup, “those with nausea in childhood continue to have more severe GI (P<.001) and somatic symptoms (P=.003)…as well as higher levels of anxiety (P=.02) and depression (P=.02).”  Anxiety and depression remained significant after controlling for baseline abdominal pain severity.
  • At the followup evaluation, the prevalence of any functional GI disorder (FGID) was 85 (48%) of those who had nausea at baseline compared with 77 (36%) for those without nausea at baseline.

In their discussion, the authors reiterate findings from previous work on this patient sample: “current and lifetime diagnoses of anxiety disorders are substantially higher in adolescents with a history of FAP [functional abdominal pain] compared with healthy controls (lifetime, 51% vs. 20%; current 30% vs 12%). The lifetime risk of depressive disorder is also significantly higher in those with FAP (40% vs. 16%).”  They also note some limitations in their work, including the absence of formal screening for postural orthostatic tachycardia syndrome (POTS).

My take (borrowed from authors): This study “suggests that nausea is more than just a comorbid symptom of FAP and may have a different underlying etiology” and increases likelihood of persistent symptoms as well as anxiety and depression.

Briefly noted: RJ Shulman et al. Clin Gastroenterol Hepatol 2017; 15: 712-9. This randomized, double-blind study showed that added psyllium reduced frequency (but not severity) of abdominal pain in children (n=103) with irritable bowel syndrome. Psyllium was dosed at 6 g/day for 7-11 year olds, and 12 g for 12-18 year olds. Interestingly, this study did not show that psyllium caused a difference in normal stools or other mechanistic reasons for improvement, like breath hydrogen, breath methane, intestinal permeability or microbiome composition.

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More Data for Ustekinumab in Crohn’s Disease

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Briefly noted: C Ma et al. Inflamm Bowel Dis 2017; 23: 833-9.  This retrospective study examined the response to ustekinumab in 104 patients with Crohn’s disease.  All patients had achieved a steroid-free ustekinumab induction.  92.3% had failed anti-TNFα therapy.

Key findings:

  • 71.8% maintained a response at 52 weeks
  • 64.4% maintained an endoscopic or radiographic response

POWER — Practice Guide on Obesity and Weight Management, Education, and Resources

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Recently, the American Gastroenterological Association (AGA) has published a large amount of information regarding obesity and the potential role for gastroenterologists.  In addition to publishing an entire Special Issue supplement of Gastroenterology (152: (7): 1635-1801, the AGA has published a “white paper” (Clin Gastroenterol Hepatol 2017; 15: 631-49).  The AGA has also addressed coding issues and episodic care issues: Clin Gastroenterol Hepatol 2017; 15: 650-64.

Some useful points from these articles:

  • “Severe obesity [as classified by] the American Heart Association…BMI>120% of the 95% for age and sex or a BMI ≥35” (“class 2 obesity in adults”) Class 3 obesity is BMI >140% of 95% for age and sex or a BMI ≥40.
  • Intensive lifestyle interventions ‘average weight losses of up to 8 kg in 6 months’ but maintaining weight loss has been a challenge. “However, both the DPP and Look AHEAD have shown that weight loss, followed by substantial weight regain, was associated with greater improvements in health than not having lost weight at all.”
  • Good idea to review medications that affect weight.  Medications associated with weight gain include antidiabetics, some antihypertensives (eg. nadolol, propranolol), antidepressants (eg. lithium, mirtazapine, SSRIs, tricyclic antidepressants), antipsychotics (clozapine, olanzapine, quetiapine, risperdione), some antieleptics (carbamazepine, gabapentin, pregabalin, valproic acid), 1st generation antihistamines and glucocorticoids.
  • Is there a best diet? On this topic, the authors (pg 1749 of supplement): “there appears to be little weight loss advantage or difference in metabolic health outcomes between dietary approaches and improvements in health are relative to degrees of weight loss.  Caloric restriction is the fundamental premise of every successful weight loss strategy, whether that is achieved by lowering fat or carbohydrate, fasting, or using meal replacements...the best diet ultimately is the one you can stick to long enough“

The information available in these publications are overlapping and cannot be summarized adequately in a short post.  The white paper, in particular, does an excellent job of summarizing the reasons for obesity, the steps a clinician should take, identification of comorbidities, management (diet, exercise, pharmacologic agents, endoscopic therapies, and surgery), and outcomes.

My take (borrowed from the authors):  “obesity is possibly the greatest health care issue of our day…Although lifestyle changes, including an individualized reduced-calorie diet and physical activity, are the cornerstones of treatment, new medications and bariatric endoscopic therapies and surgery can be effective tools.”

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IBD Shorts and Postop Crohn’s Management

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C Ma et al. Inflamm Bowel Dis 2017; 23: 833-9.  This retrospective study examined the ongoing response to ustekinumab in 104 patients with Crohn’s disease.  All patients had achieved a steroid-free ustekinumab induction.  92.3% had failed anti-TNFα therapy.Key findings:

  • 71.8% maintained a response at 52 weeks
  • 64.4% maintained an endoscopic or radiographic response

Related blog post: Closer Look at Ustekinumab Data

O Truffinet et al JPGN 2017; 64: 721-25. This small study with 8 children with Crohn’s disease examined the use of tacrolimus.  Six of eight showed a response to tacrolimus (target 8-15) with a clinical response at 2 months and 4 of 8 in clinical remission.  Adverse effects were common, occurring in 6 of 8.  These included renal dysfunction, diabetes, paresthesia and tremor.

J Adler et al.  JPGN 2017; 64: e117-e124. Using ImproveCareNow registry, the authors identified perianal disease (PD) in 1399 of 6679 cases (21%).  PD was more common in blacks than whites: 26% vs. 20%.  Overall, this study showed a higher rate of PD than previously recognized.

J Amil-Dias et al JPGN 2017; 64: 818-35.  This is an ESPGHAN IBD Porto Group guideline for surgical Crohn’s disease management in children.  There are 25 graded statements.  Here are a few:

  • #7 & #8. If needing surgery for CD pancolitis, the authors recommend subtotal colectomy and ileostomy.  Possible reanastomosis at later date if no significant rectal and/or perianal disease.  Ileal pouch-anal anastomosis is NOT recommended.
  • #13. Monitor Vitamin B12 if >20 cm resection of terminal ileum
  • #16. Postoperative management “should be based on ileocolonoscopy.” Figure 1 details recommendations, including need for assessment postoperatively.
  • In patients with high-risk factors, anti-TNF therapy is recommended postoperatively.  In those without high-risk factors, the authors indicate that thiopurines are reasonable with and advancing to anti-TNF if Rutgeerts i2 or greater at followup assessment.  High-risk factors include growth failure, short duration from diagnosis to surgery, extensive resection (>40 cm), and penetrating disease.

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One Way Fecal Microbiota Transplant May Work: Changing Bile Acids

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Breifly Noted:

From MedPage Today: Fecal transplant success may depend on bile acid metabolism

An excerpt:

the transplants change patterns of bile acid metabolism in the gut, making the environment inhospitable to C. diff colonization.

In three studies reported at Digestive Disease Week (DDW) 2017, it was demonstrated that individuals with C. diff who respond to fecal transplant showed a different pattern of microbiota species composition compared with baseline and/or with those who fail to respond. But that’s not all: the responders also showed distinct, altered profiles of those elements involved in bile acid metabolism.

Vincent Van Gogh; Hopital Saint-Paul (1889)

 

Professional Resources: Gastric Feeds, Celiac Disease

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Many of our patients use Farrell bags to help with their enteral feedings; though, this decompression system is often used incorrectly.  The following is a link to the company’s instructions on how to use this product correctly. Halyard Health: Farrell System

Note: I do not have commercial ties.

From NASPGHAN -Celiac resource: NASPGHAN Clinical Guide For Celiac Disease

I reviewed this website.  Overall, this is a useful resource.  There are multiple links that address some of the nuances with celiac disease.  Interestingly, the website is not entirely consistent in its recommendations. For example, under the link “my parent/child has celiac” recommendations for screening family member are for TTG IgA and IgA (if asymptomatic) whereas under the health professional area, after diagnosis, the website recommends much more extensive testing of family members: HLA DQ2/DQ8 genetics, TTG IgA, IgA, and anti-DGP IgG testing

 

Costs of Rumination

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Reading a recent study (A Alioto et al. J Pediatr 2017; 185: 155-9) reminded me of “My Cousin Vinny.”  In a crucial scene, Mona Lisa Vito (Marisa Tomei) proves that the accused killers were not the killers by identifying tire tread marks that were inconsistent with the defendants’ car simply by looking a photograph.

Similarly, the authors of this retrospective report highlight the extensive cost of that children undergo for evaluation of rumination when simple observation might suffice.

Key findings:

  • Consecutive patients (n=68, 2009-2015) admitted to their inpatient rumination treatment program had undergone an average of 8.8 tests at a cost of $19,795.
  • Few tests were beneficial. Most common tests were esophagogastroduodenoscopy, upper gastrointestinal series, and abdominal ultrasound scan.

Limitations:

  • The cohort is derived from a quaternary center
  • The number of tests may be underestimated as the tests were done by the referring center; thus, the authors were reliant on data provided to them

Other comments:

  • A good clinical history can suffice to establish the diagnosis. “Observing the patient eat and/or drink and then ruminate is perhaps even more useful.”
  • “We strongly suggest that if a patient meets the symptom-based criteria for rumination syndrome, no further diagnostic testing is warranted. That said, …various phenotypes of the syndrome may make the diagnosis less clear-cut” and some testing could be needed.
  • Rumination may be “symptomatic for over 2 years before the diagnosis is established” (Pediatrics 2003; 111: 158-62)

My take: Not every doctor is as good at doctoring as Vinny Gambini is at lawyering. That being said, the authors note “for patients who present with repeated effortless regurgitation and vomiting of food that begins soon after they eat or drink, is not preceded by retching, and does not occur during sleep, there are very few other diagnoses to be considered.”

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

Omaha Beach 2017

Surgery for Reflux Works Best in Those Who Need it the Least

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In a recent retrospective study (JT Krill et al. Clin Gastroenterol Hepatol 2017; 15: 675-81), the authors reinforce the notion that surgery works best for reflux patients whose symptoms respond best to medical therapy.

Background: In this study, 196 patients with normal anatomy were identified, though 81 had inadequate follow-up at 1 year.  This left 115 patients (median age ~52).  This study examined patients with typical reflux symptoms (regurgitation, heartburn) (n=79 of 115, 68.7%) and extraesophageal symptoms, like cough, hoarseness, and throat clearing (n=36 of 115, 31.3%).  It is noted that 2/3rds of those with extraesophageal symptoms had coexisting typical GERD symptoms.  Most patients had a Nissen fundoplication but some underwent a Toupet fundoplication.

Key findings:

  • 91.5% of those with typical reflux symptoms (who  had responded to medical therapy) were in remission at 1 year; in comparison, only 33.3% (P <.01) of those with extraesophageal symptoms along with poor response to acid suppression therapy exhibited remission following fundoplication.
  • “The severity of acid reflux on pH monitoring and larger hiatal hernia size were associated with a more favorable outcome at 12 months.”  All patients had either abnormal pH monitoring or endoscopic esophagitis prior to surgery.  Only those with severe reflux had increased likelihood of response to surgery.

Limitations: retrospective study, 81 of 196 patients were excluded due to lack of followup

My take: This study is consistent with other studies in suggesting that reflux surgery is less effective in those who do not respond to medical therapies and who have atypical symptoms.

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Favorable Fish Oil Outcomes in High Risk Preterm Infants

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Briefly noted: M Sorrell et al. JPGN 2017; 64: 783-88. In this small study with 13 infants (mean gestational age of 28 weeks) who had short bowel syndrome or severe dysmotility and direct bilirubin ≥4 mg/dL (mean 9.8 at enrollment), patients received a fish oil-based lipid emulsion (1 g/kg/d). They were compared with 119 GA-matched controls.

Overall, the authors found the fish oil supplement to be safe.  All patients had resolution of cholestasis. They note the difficulty of proving effectiveness and performing studies in this population.  “Neonatologists…find themselves faced with …a growing body of uncontrolled data that suggests benefits of an unapproved treatment…An attempt to perform a randomized controlled comparison of a plant-based lipid emulsion to FishLE in preventing PNALD in infants at risk was terminated early after an interim analysis revealed much lower than expected incidence of PNALD…[making] trials ethically problematic.”

My take: The data remain incomplete and make it difficult to use a therapy like Omegaven that is quite expensive (not covered) and not FDA approved.  The availability of SMOFlipid is likely to result in less usage of plant-based soy products.

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Dilatation for Eosinophilic Esophagitis -Pediatric Data

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The most recent data in adults has indicated that dilatation for eosinophilic esophagitis (EoE) likely does not have increased risk compare to esophageal dilatation for other causes.  A recent pediatric retrospective study (C Menard-Katcher et al. JPGN 2017; 64: 701-6) reaches a similar conclusion.

In this study over a 5-year period, there were 68 dilatations among 40 patients with EoE.

Dilatation was considered complete if a diameter of 15 mm (45 French) was reached or if a deep rent in the mucosa was evident; small (<0.5 cm) shallow rents were “not considered criteria for cessation of dilations.”

Methods:

  • In their institution, areas of narrowing >5 cm in length were typically treated with Maloney dilators and shorter narrowings were managed with balloon dilators (through the scope).
  • For Maloney bougie dilators, often dilations started at 24 French; typically 30 French if scope could traverse narrowing.
  • For balloon, often dilations started at 10 mm.  Fluoroscopy was often used at initial dilation (12 of 19).
  • 17 of 40 required more than one dilation in the study period

Some of the key findings:

  • Approximately 5% of their EoE patients needed dilations.
  • Patients with EoE who needed dilations were older than EoE patients who did not need this: 13.8 vs 8.2 years
  • Postoperative chest pain was most common adverse event, affecting 15% of dilations. In this small series, there were no perforations.
  • At this institution, half of the patients had dilation at their diagnostic endoscopy before starting EoE-specific therapy. However, as noted in their commentary, medical management may obviate the need for dilations.
  • Medical management consisted of “swallowed steroids (62%), dietary therapy (12%) or both (24%).”

My take: Overall, this study indicates that dilations are fairly safe in the EoE population. That being said, in my view, all dilations carry a small but significant risk.

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Musee d’Orsay, Naissance de Venus, Alexandre Cabanel, 1863