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, 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 section chief for pediatric gastroenterology at Children’s Healthcare of Atlanta at Scottish Rite and 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 – women physicians – physicians who speak Spanish – cutting edge research – on-site nutritionists – on-site psychology support – 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 relationships with pharmaceutical companies or other financial relationships to disclose.

Briefly Noted: Outpatient Liver Biopsy

A small retrospective study (R Bolia et al. JPGN 2017; 65: 86-88) with 497 patients (626 biopsies) found that all complications were identified within 8 hours.  Thirty (48%) had complications, with a subcapsular hematoma being most common (n=14).  Less common adverse events included fever (n=5), skin site ooze (n=3), intraperitoneal bleeding (n=3), hemobilia (n=2), anaphylaxis to gelfoam (n=2), and sepsis (n=1). In this study, the majority of biopsies were performed by interventional radiology (n=492); though, the complication rate was similar in both groups.

The authors conclude that their data support the outpatient liver biopsies in children.

My take: I disagree with the authors’ conclusion to some extent.  Their population is too small to detect rare but severe complications.  Our empiric practice is watch children older than 6 years of age for 6 hours and watch younger children (or others deemed at increased risk) for 24 hours.

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Prague

Slim Pickings: Data for 2nd-Line Autoimmune Hepatitis Pediatric Therapy

A recent study (AN Zizzo et al. JPGN 2017; 65: 6-15) performed a systematic review and meta-analysis of pediatric autoimmune hepatitis (AIH) studies.

The most remarkable finding was that there were only 76 patients from 15 qualifying studies.

Other findings:

  • Response to mycophenolate mofetil (MMF) with 34 patients was 36% (according to abstract) at 6 months  (discrepancy in article –results state 38% response)
  • Response to cyclosporine with 15 patients was 83% (discrepancy in article –results state 86% response)
  • Response to tacrolimus with 4 patients was 50%
  • Adverse effects were very common, particularly with cyclosporine (64% noted at least 1 adverse effect)

The article has an associated editorial (N Kerkar, pg 2-3).  “The adverse event profile of cyclosporine with gingival hyperplasia, hypertrichosis, nephrotoxicity, and neurotoxicity made it challenging for long-term use in children.”  Besides the small number of patients, “the studies that were included were largely “observational”‘ which limits their findings as well.  The study authors recommend MMF as the preferred option for 2nd-line therapy.

My take: Fortunately, most patients with autoimmune hepatitis respond to first line therapy with azathioprine/steroids.  It is unclear what is the optimal 2nd-line treatment for refractory patients.

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Egret, Shem Creek

Will Emerging Therapies for Fatty Liver Disease Be Affordable?

With non-alcoholic steatohepatitis (NASH), there are currently no established medical therapies.  However, several candidate medications look promising. However in recent years, many new medications have come with an impressive price tag and this has led to questions about whether emerging therapies for NASH will be affordable.

A recent article looked at the medication Obeticholic Acid, which was approved for treating primary biliary cholangitis.  It is possible that it will be helpful for NASH.  Yet, its cost , currently, is about $70,000 per year

GIHepNews: Despite clinical promise, obeticholic acid may be too expensive for treating NASH

Here’s an excerpt:

In the 72-week Phase II trial, called FLINT, 273 men and women with NASH were randomly assigned to receive OCA or placebo (Lancet 2015;385:956-965). Liver histology improved in 45% of those receiving OCA versus 21% in those receiving sham therapy (P=0.002). An increased risk for pruritus was the most notable adverse event among patients taking OCA (23% vs. 6% for placebo), according to the researchers. Based on the favorable benefit–risk results of the Phase II study, a Phase III trial is ongoing…

The expected benefit of OCA over lifestyle modifications for all the major long-term outcomes, such as decompensated cirrhosis (10% vs. 9.4%), liver-related mortality (9% vs. 8.1%) and transplant-free survival (72.2% vs. 71.5%), were relatively modest, the researchers reported. Those differences resulted in a cost per quality-adjusted life-year saved of $5.2 million with the assumption that 16% of patients would relapse…

 “If the efficacy compared to placebo is of the same order found in the FLINT trial, the current cost of the drug would be prohibitive in a population-based context,” said Dr. Lavine, who was a co-investigator on the trial.

My take: Given the growing burden of NASH, new effective treatments are needed.  In my view, though, cost-effectiveness has to be a consideration.

Prague Castle

NASH: What Helps Beyond Weight Loss?

Full text from ACG article: NASH: What Helps Beyond Weight Loss?

The article reinforces the value of weight loss and exercise for nonalcoholic steatohepatitis (NASH).  It suggests that Vitamin E and/or pioglitazone may be helpful. Many more medications are being evaluated.

My take: As of now, losing weight and exercise remain the cornerstone for NASH treatment.

Long Distance (Medical) Relationships Don’t Always Work

Another study (NZ Borren et al Inflamm Bowel Dis 2017; 23: 1234-9) has shown detrimental outcomes due to distance from the health care team.

In this study with 2136 patients with IBD (1197 Crohn’s disease, 9393 ulcerative colitis) with mean age of 41 years, the distance from the hospital (Massachusetts General) was compared with need for IBD-related surgery and secondary outcomes of needing biological and immunomodulator therapy.

Key findings:

  • In the four quartiles, mean distance was 2.5, 8.8, 22.0, and 50.8 miles.
  • Need for surgery was increased with distance from hospital: closest with odds ratio of 1.0, quartile 2 had OR of 1.68, quartile 3 had OR of 1.94, and quartile 4 had OR of 2.44

According to the authors, with other indications besides IBD, “over three-quarters of the examined studies demonstrated a distance-decay association with worse outcomes in individuals living further away from health care facilities.  Limitation: it is possible that patients who travel a greater distance have more disease severity and that those who have milder diseases are more likely to receive care closer to home.

My take: When highly qualified subspecialists are far away, the associated reduced access likely counters this potential benefit.  Early effective therapy is important in reducing complications.

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Shem Creek, SC

Distance from Transplant Center -Not a Good Thing for Chronic Liver Disease

It is said that “absence makes the heart grow fonder.”  This expression certainly cannot be extrapolated to the liver.  A recent study (DS Goldberg et al. Clin Gastroenterol Hepatol 2017; 15: 958-60) showed that increased distance to a liver transplant center was associated with higher mortality for patients with chronic liver failure (CLF).

This study examined 16,824 patients with CLF.  In the cohort (879, 5.2%) who lived  >150 miles from the closest LT center there was a 20% higher mortality rate (Hazard ratio of 1.20; P <.001).  According to the authors, mortality with distance “modeled as a continuous variable per unit increase in 50 miles.”

From the discussion:

  • “For patients with CLF, transplant remains the only option for long-term survival. Yet for the 11 out of 12 who are never transplanted, access to specialized care may still prolong life.”
  • Limitations: This study could not account for socioeconomic factors or control for geographical variation in care.  With regard to the later, death rates from liver disease are lowest in New York, where the entire population is within 150 miles of a transplant center.  In contrast, in New Mexico and Wyoming, which have the highest age-adjusted death rates, more than 95% of patients live >150 miles from a transplant center. However, there may be many other differences in care besides distance in these regions.

My take: This study, though with some limitations, bolsters the view that patients with chronic liver disease (and probably other chronic diseases) live longer if in proximity to specialized care.

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Exquisite windows in St. Vitus Cathedral, Prague