About gutsandgrowth

I am a pediatric gastroenterologist at GI Care for Kids (previously called CCDHC) in Atlanta, Georgia. The goal of my blog is to share some of my reading in my field more broadly. In addition, I wanted to provide my voice to a wide range of topics that often have inaccurate or incomplete information. Before starting this blog in 2011, I would tear out articles from journals and/or keep notes in a palm pilot. This blog helps provide an updated source of information that is easy to access and search, along with links to useful multimedia sources. I was born and raised in Chattanooga. After graduating from the University of Virginia, I attended Baylor College of Medicine. I completed residency and fellowship training at the University of Cincinnati at the Children’s Hospital Medical Center. I received funding from the National Institutes of Health for molecular biology research of the gastrointestinal tract. I have authored numerous publications/presentations including original research, case reports, review articles, and textbook chapters on various pediatric gastrointestinal problems. Currently, I am the chair of the section of nutrition for the Georgia Chapter of the American Academy of Pediatrics. In addition, I am an adjunct Associate Clinical Professor of Pediatrics at Emory University School of Medicine. Other society memberships have included the American Academy of Pediatrics, the Food Allergy Network, the American Gastroenterology Association, the American Association for the Study of Liver Diseases, and the Crohn’s and Colitis Foundation. As part of a national pediatric GI organization called NASPGHAN (and its affiliated website GIKids) I have helped develop educational materials on a wide-range of gastrointestinal and liver diseases which are used across the country. Also, I have been an invited speaker for national campaigns to improve the evaluation and treatment of gastroesophageal reflux disease, celiac disease, eosinophilic esophagitis, and inflammatory bowel disease (IBD). Some information on these topics has been posted at my work website, www.gicareforkids.com, which has links to multiple other useful resources. I am fortunate to work at GI Care For Kids. Our group has 17 physicians with a wide range of subspecialization, including liver diseases, feeding disorders, eosinophilic diseases, inflammatory bowel disease, cystic fibrosis, DiGeorge/22q, celiac disease, and motility disorders. Many of our physicians are recognized nationally for their achievements. For many families, more practical matters include the following: – 14 office/satellite locations – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support for abdominal pain and feeding disorders – participation in ImproveCareNow – office endoscopy suite (lower costs and easier scheduling) – office infusion center (lower costs and easier for families) – easy access to nursing advice (each physician has at least one nurse) I am married and have two sons. I like to read, walk/hike, exercise, swim, and play tennis with my free time as well as go to baseball games. I do not have any financial relationships with pharmaceutical companies or other financial relationships to disclose. I have participated in industry-sponsored research studies.

Changing the Dietary Approach with Eosinophilic Esophagitis

A recent study (AF Kagalwalla, JB Wechsler, K Amsen, S Schwartz, M Makhija, A Olive, CM Davis, M Manuel-Rubio, Seth Marcus et al.  Clin Gastroenterol Hepaot, 2017; 1698-1701) is going to help shake up the dietary management of eosinophilic esophagitis (EoE).  Our group GI Care for Kids, led by Seth Marcus, was one of the four centers which participated in this study of a four food elimination diet (FFED or 4-FED).

This prospective study enrolled 78 patients. IN those who did not respond to twice daily proton pump inhibitor therapy, subjects were instructed to restrict cow’s milk, wheat, egg, and soy. Patients underwent serial challenges (8 week for a challenge) with followup upper endoscopy to each food to determine response; 25 patients completed the challenge to all four foods. Key findings:

  • 64% (n=50) had remission (Eos <15/hpf) with the FFED
  • Symptom scores decreased in 91% of the histologic responders
  • Among those who completed additional challenges: 22/26 (85%) had reactions to cow’s milk, 10/30 (33%) had reactions to wheat, 14/40 (35%) had reactions to eggs, and 8/43 (19%) had reactions to soy
  • Among those (n=25) who completed challenges to all four foods, reactions to food: 84% milk, 28% wheat, 8% eggs, 8% wheat
  • Among those (n=25) who completed challenges to all four foods, reactions occurred to a single food-groups in 64%, two food-groups in 20%, three-food groups in 8%, and four-food groups in 8%.  Thus 36% had more than a single-food group reaction.

This study shows that the FFED provides similar efficacy to the six-food elimination diet (SFED) and is less restrictive.  It offers the prospect of less time to complete food reintroduction and fewer upper endoscopies

Limitations: nonrandomization, absence of control group, selection bias.  The fact that 24 patients dropped our before completing reintroduction highlights the difficulty of maintaining these diets in clinical practice.

In the associated editorial (S Eluri, ES Dellon, pages: 1668-9), the authors reiterate that the SFED (or 6-FED), which includes nuts and seafood, had histologic response rates typically between 69%-72% and that this study shows a similar response. They note that dairy elimination alone has had response rates ranging from 43% to 65%.

In addition, they discuss a 2-food elimination diet (milk and wheat).  In a recent study (J Molina-Infante, et al. Gastroenterol 2017; 152: S207), the authors started with a 2-FED with histologic response of 43% and if not responding would advance to 4-FED and 6-FED.  This approach was more efficient and further limited endoscopies.

My take: In those patients who are treated with a dietary approach, the 4-FED is a sensible initial therapeutic approach and an improvement from the 6-FED.  Though there is slightly higher initial response to 6-FED, the 4-FED allows more efficiency at identifying the trigger foods and lessened patient burdens with regard to endoscopy, diet complexity, and cost.

Related study: EA Erwin et al. JPGN 2017; 65: 520-5. This study showed that patients multiple IgE antibodies (≥ 0.1 IU/mL) to foods correlated with the likelihood of identifying eosionphilic esophagitis (≥ 15 eos/hpf):

  • In this cohort, among males, positive IgE antibodies to zero foods had a positive predictive value of 22%, 1-3 foods 52%, and 4-5 foods of 77%
  • In this cohort, among females, positive IgE antibodies to zero foods had a positive predictive value of 10%, 1-3 foods 29%, and 4-5 foods of 56%

Related blog posts:

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.

 

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#NASPGHAN17 Eosinophilic Esophagitis Session

This blog entry has abbreviated/summarized these presentations. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

This is a long post –highlighting four separate talks on eosinophilic esophagitis.

PPI Use in Esophageal Eosinophilia: Recommendations from the recent AGREE conference

Glenn Furuta  Children’s Hospital of Colorado

Key points:

The term PPI-REE (proton pump inhibitor-responsive eosinophilic esophagitis) may not be needed.  PPI-REE is quite similar to eosinophilic esophagitis based on molecular and clinical features.  The main difference being that this subset responds to PPI therapy.

 

Characterization of CYP2C19*17 Polymporphisms Among Children with PPI Responsive EoE and EoE

James Franciosis et al.  Nemours Children’s Hospital Orlando

My take: This cool presentation offered a potential explanation of why some patients respond to PPIs (so called “PPI-REE”) from those with EoE that does not respond to PPIs.  This is pertinent because on a molecular basis the disease appears to be the same.  The difference in PPI-REE from EoE may be how the patient metabolizes PPI.  Those EoE patients who metabolize PPIs “extensively” are much less likely to respond to this therapy.

Eosinophilic esophagitis: Now an “Oldie” -But with increased interest and new research, a “Goodie”

Chris Liacouras  Children’s Hospital of Philadelphia

This lecture covered an enormous amount of material.  Here are a few slides.

Final Lecture (from November 3rd presentation):

Key points:

  • Endoflip is a new tool that helps determine esophageal distensibility.  Improved distensibility indicates less fibrostenotic disease which is one long-term goal.
  • Response to treatment has been correlated in improvement in Endoflip measurements.
  • There are no FDA approved medications at this point for EoE, though topical steroids may be approved soon.

#NASPGHAN17 Why Rome IV Criteria are important

More information from this year’s annual NASPGHAN meeting.

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

The following slides highlight a terrific lecture by Carlo DiLorenzo (Nationwide Children’s Hospital).  Subsequently, I’ve included slides from Miranda van Tilburg (UNC); I was unable to attend her lecture and found some of the slides via twitter.

Key points:

  • Rome IV criteria are helpful, particularly with less common presentations like rumination
  • There has been an increase in nausea.  Morning nausea can be equated as a marker of anxiety until proven otherwise.
  • There is improved wording. “After appropriate medical evaluation, the symptoms cannot be attributed to another condition” may help facilitate the diagnosis of irritable bowel syndrome, for example, in patients with IBD who are in remission.

From Miranda Tilburg:

#NASPGHAN17 Psychosocial Problems in Adolescents with IBD

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Slides from syllabus: APGNN Syllabus 2017

Key points:

  • ~30% of pediatric IBD patients have anxiety or depression.  This has not been shown to be related to disease activity.
  • Advice for parents: “Listen more and talk less.”
  • Antidepressants, when indicated, are about 6 times more likely to be helpful than detrimental

In the following slide, the term “normalize” indicates that checking on emotional health is part of a routine (eg. ‘we ask all our patients to complete this screening’)

#NASPGHAN17 Presentation: Reducing Hospitalization in Intestinal Failure Patients

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Risk Factors for Hospitalization Among Pediatric Intestinal Failure Patients

Tatyana Hofmekler, Janet Figueroa, Hilina Kassa, Rene Romero, Andi Shane.

Dr Hofmekler is now part of GI Care for Kids (my group) and provided a terrific presentation.

NASPGHAN Annual Mtg 2017

Key points:

  • In this study, there were no social or demographic factors which were identified which were associated with increased hospitalization
  • Having a colon and an ileocecal valve lowered the risk of hospitalization
  • The use of SBBO treatment was associated with increased hospitalization though this may have been a marker of more severe disease
  • Vascular catheter infections were reduced compared to study at same institution previously but remained an important risk factor for hospitalization

My take: this study illustrates the challenges in reducing hospitalization.  While the authors did not identify social/demographic factors, my experience is that there are some families who are much more capable than others in taking care of children with complex problems.  If all children had the best parents, that would truly allow the hospitalization rate to be reduced much lower.

 

#NASPGHAN17 Presentations at Annual Meeting: GGT in PSC, Nutrition for Intestinal Failure

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

Improvement in GGT Predicts Event-free Survival in Primary Sclerosing Cholangitis Regardless of Ursodeoxycholic Acic Treatment. 

Mark Deneau et al. (Grand Watkins Prize).

Key points:

  • PSC is difficult to study due to its rarity and due to its slow progression; thus surrogate biomarkers are needed.
  • Alkaline phosphatase is not a good biomarker in children
  • GGT level at one year after diagnosis was predictive of prognosis
  • Ursodeoxycholic acid does not appear to be effective

Optimizing Nutrition in Intestinal Failure

Justine Turner, University of Alberta

Key points:

  • Human milk is an ideal “formula” for infants, including those with intestinal failure
  • Oral feedings are important
  • Combination of bolus feeds and continuous feeds is reasonable
  • SMOFlipid allows higher lipid dose administration without hepatoxicity; this may improve cognitive outcomes
  • Amino acid based formulas have higher osmolality which can contribute to diarrhea

Patients with >50% of small bowel and >50% of colon were most likely to achieve enteral autonomy (GIFT registry)

 

 

#NASPGHAN17 Annual Meeting Notes (Part 2): Year in Review

This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

This first slide shows the growth in NASPGHAN membership:

Year in Review

Melvin Heyman  Editor, JPGN

This lecture reviewed a number of influential studies that have been published in the past year.  After brief review of the study, Dr. Heyman summarized the key take-home point.