AGA Patient Information: Iron deficiency anemia
There are a lot of other good patient handouts on this website: AGA GI Patient Center
More kid focused handouts: GIKids.org
This is a fairly good patient handout though there are several differences between children and adults.
DA Carlson et al. Gastroenterol 2023; 165: 552-563. Open Access! A PhysioMechanical Model of Esophageal Function in Eosinophilic Esophagitis
215 adults with EoE who completed FLIP during endoscopy were included in a cross-sectional study. FLIP helped separate the physiomechanical properties of esophageal function in this cohort. The criteria used to define the PhysioMechanical classification in EoE with a representative FLIP panometry image for each classification. Normal compliance was defined as a DP >17 mm and body compliance >450 mm3/mm Hg; reduced compliance (fibrostenosis) was defined by DP ≤17 mm or compliance ≤450 mm3/mm Hg. Normal EGJ opening was defined as a maximum EGJ diameter ≥16 mm; reduced as maximum EGJ diameter <16 mm. ∗Spastic-reactive contractile response (SRCR) with normal body distensibility and normal EGJ opening was assigned as “achalasia pattern” (n = 1 in this cohort).
Key findings:
My take: FLIP testing helps define the mechanism of esophageal dysfunction in patients with EoE. Longer duration of symptoms was associated with more severe esophageal dysfunction.
Related blog posts:
PF Farmer et al. J Pediatr 2023; 259: 113487. Single-Center Analysis of Essential Laboratory Testing in Patients with Newly Diagnosed Celiac Disease
In this study, the authors analyzed laboratory testing results from pediatric patients newly diagnosed with celiac disease (2018-2021) to determine the usefulness of each test derived from recommended guidelines (J Snyder et al. Pediatrics 2016; 138: e20153147). Screening protocols in their center resulted in an estimated cost of approximately $320,000 during the study. Tests at diagnosis included hemoglobin, alanine/aspartate aminotransferase, ferritin, iron, TSH, Free T4, and vitamin D screening. These screening tests were done in ~80% of 468 patients.
Key findings:
My take: This is a very useful study and indicates that curtailing initial testing for celiac disease could reduce costs substantially and without compromising care. This would include not checking a serum iron, a free T4, or hepatitis B studies. The authors note that the value of Vit D testing is also questionable but may be worthwhile due to increased risk of bone disease in individuals with celiac disease.
Related blog posts:
D Glynn et al. J Pediatr 2023; 259: 113486. Nonanaphylactic Variant of Alpha-Gal Syndrome as an Etiology for Chronic Gastrointestinal Symptoms in Children
Background: A CDC report showed that between 2010 and 2022, more than 110,000 suspected cases of alpha-gal syndrome were identified. The majority of cases are linked to bites from the lone star tick which affects much of the U.S. (map below) as well as Central and South America, Asia, Africa, Australia and parts of Europe.
Findings: This study reports 3 pediatric patients who presented with only nonanaphylactic symptoms of alpha-gal syndrome. These patients with recurrent gastrointestinal distress and emesis after consuming mammalian meat, even in the absence of an anaphylactic reaction.
The diagnosis in these three patients was established by history, serum alpha-gal immunoglobulin E elevation and response to avoidance of red meat.
My take: Checking a serum Alpha-gal IgE seems like a good idea in some children with unexplained abdominal pain with episodic exacerbation with vomiting, especially if tick exposure. Anecdotally, I have checked this a few times and so far I have not I identified a case. Most cases of Alpha-gal will be associated with urticaria.
Related blog post: Tick Bites Can Lead to Allergy to Red Meat
CDC: Alpha-gal syndrome “Symptoms commonly appear 2-6 hours after eating meat or dairy products, or after exposure to products containing alpha-gal (for example, gelatin-coated medications).”
CDC: Food products that may contain alpha-gal: Mammalian meat (such as beef, pork, lamb, venison, rabbit, etc.) can contain high amounts of alpha-gal. Food products that contain milk and milk products typically contain alpha-gal (though many patients tolerate dairy products)
Foods that do NOT contain alpha-gal (unless cross contamination):
Case history: A well-nourished previously healthy 20 month old was admitted to the hospital with a one week history of frequent vomiting. He had a history of frequent lint ingestion. He had been seen by three different health care providers during the week prior to his admission.
At the time of admission, he had numerous electrolyte derangements (Na 124, K 3.2, CL 76) and acute kidney dysfunction with a BUN of 118 and Creatinine of 3.06. He had severe multisystem disease including severe ventricular dysfunction (BNP 2196). He needed an oscillator ventilator, dialysis and cardiac medications (including epinephrine, and milrinone).
He had an extensive evaluation. After he had stabilized and then markedly improved (12 days after admission), an UGI study demonstrated an obstruction near the 2nd-3rd portion of the duodenum with a dilated proximal duodenum.
UGI study:
Due to the obstruction which was thought to be anatomic, the GI service deferred management to pediatric surgery. The surgical service requested GI inspection with endoscopy immediately prior to surgery. If a bezoar was identified, the surgical plan was for a mini-laparotomy. If not, the surgical plan was for laparoscopy repair.
Endoscopy findings: There was a narrowed opening (different orientation of same narrowing in both pictures) with a string-like material.
Surgical findings: A duodenal web with a piece of lint was identified. The patient had a laparoscopic wedge excision with a transverse closure of the duodenotomy. The lint may have occluded the tiny opening of the web that he had been living with since he was born.
My take: This is the first time I have seen the endoscopic appearance of a duodenal web.
In my view, this was a ‘great case.’ In a commentary by Jerome Groopman (N Engl J Med 2004; 351:2043-2045), his wife noted that a case is “a great case because you not only make the diagnosis — you do something fundamental about it. You can really help.” However, Dr. Groopman stopped using the words, ‘a great case’ after his personal experience when his son was severely ill as an infant with a bowel obstruction due to intussusception: “For me and for Pam, the experience had no resonance of “a great case.” There was no intellectual pleasure in solving a clinical puzzle, no charge of exhilaration from the drama of the operation. Instead, there was terror, raw and palpable, as we realized how close we had come to burying our first son….I still find myself unable, except in retrospect, to retrieve the language of my youth and speak about “a great case.” It is as if medicine at this stage of my life has split into two streams — a current of marvelous biology and an undertow that pulls at the soul.”
C Wester et al. MMWR 2023; 72 (26): 716-720. Open Access! Hepatitis C Virus Clearance Cascade — United States, 2013–2022 (starts on page 16 of PDF)
Key findings:
My take: Improving access to HCV treatment has the potential to save livers, save lives and save money.
Related blog posts:
For those wanting an in-depth review:
Eric Topol: “The GLP-1 and now triple G-Agonists are exceeding expectations as weight loss drugs. Benefits for cardiovascular outcomes, possibly Type 1 diabetes, addiction, and more are reviewed in the latest Ground Truths.” His newsletter also describes the early results of these medications with MASH/NASH with improvement in ~90%.
To get the full review, go to Ground Truths: http://erictopol.substack.com (can sign up to get regular emails on many current medical topics)
Related blog posts:
” Takeda (TSE:4502/NYSE:TAK) today announced that the U.S. Food and Drug Administration (FDA) has approved a subcutaneous (SC) administration of ENTYVIO® (vedolizumab) for maintenance therapy in adults with moderately to severely active ulcerative colitis (UC) after induction therapy with ENTYVIO intravenous (IV).1 ENTYVIO SC is expected to be available in the U.S. as a single-dose pre-filled pen (ENTYVIO Pen) by the end of October. Additionally, a Biologics License Application for an investigational SC administration of ENTYVIO for the treatment of adults with moderately to severely active Crohn’s disease is currently under review by the FDA.”
From WJ Sandborn et al. Gastroenterol 2020; 158: 562-572. Open Access! Efficacy and Safety of Vedolizumab Subcutaneous Formulation in a Randomized Trial of Patients With Ulcerative Colitis
In the VISIBLE1 Trial, dosing was IV for week 0 and 2, then every other week SC for maintenance.
Dr. Glaucomflecken Twitter Link (w/o login): Out of Pocket Maximum (1:13 min)
There are a bunch of new videos (one for everyday in September) similar to this on related topics -search 30 Days of US Healthcare. Here’s another one: 30 Days of US Healthcare: Surprise Billing (YouTube)
My take: As usual, Dr. Glaucomflecken humor sheds light on the faults in our nation’s health care insurance coverage.
TL Hedrick et al. Clin Gastroenterol Hepatol 2023; 21: 2473-2477. Open Access! AGA Clinical Practice Update on Management of Ostomies: Commentary
This article is a helpful review on ostomy care. The article reviews approaches to common problems including early high ostomy output, ostomy leakage, stoma retraction, mucocutaneous separation, dermatological problems, chronic high ostomy output, parastomal hernia, and stoma prolapse. A few of their comments:
Related blog posts:
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