Gut-Level Conversations: Pediatric Gastroenterology for the Primary Care Provider

By Glenn Duh

Why do babies regurgitate so much? Is H pylori always bad? Why is Johnny's stomachache still there after his constipation got cleared out with laxatives? What do I do with a child with a high ALT? These are but some of the common questions that pediatric gastroenterologists answer daily, and often MULTIPLE times daily, to their patients, families and fellow medical providers. Gut-Level Conversations: Pediatric Gastroenterology for the Primary Care Provider covers these, and many more, in 70 discrete topics that the author collected over the course of his career as a pediatric gastroenterologist in Southern California. This book provides a glimpse into the inner workings of the author as he tries to find the right words to paint lasting impressions in his answers. This is not a textbook, and one should not use it to study for examinations. However, laughing out loud while reading is encouraged, as long as the setting is appropriate for doing so....

• Language: English
• Publisher: Glenn Duh
• Release date: Jun 2, 2023
• ISBN: 9798215778029

Glenn Duh

Glenn, born of non-religious parents in Taiwan, was a staunch atheist and Darwinian when he first immigrated to the United States with his family at the age of 14. However, God was merciful, and used several of his high school friends as instruments of his salvation at a church retreat in July, 1983. Glenn met his wife, Karen, at a Bible study in college (UCLA), and they have two adult children. Glenn is a retired physician who was board-certified in general pediatrics and pediatric gastroenterology, and had spent more than 22 years of his career as a pediatric gastroenterologist in Downey, California, as a partner physician with Southern California Permanente Medical Group.

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I. FUNCTIONAL STUFF

Why Is the Gastritis/Reflux Medicine Not Working? (November 2017)

We often prescribe or recommend acid reducing medications or antacids for digestive ailments, usually with satisfactory results. Sometimes, these patients do have GERD or gastritis, and they respond well to treatment. Other times, they may not actually have these conditions, but they feel better anyways due to the placebo effect, which may affect nearly one-half of all patients with digestive symptoms. The frustration occurs when the medications don’t work. There are many possible causes for treatment failure; fortunately, most of these can be identified with reasonable ease:

The medications are not taken properly

Proton pump inhibitors such as omeprazole have slow onsets of acid reducing effect. Patients who use these medications only as-needed for acute symptoms likely will not experience much immediate benefit. On the other hand, H2RA class medications, e.g., ranitidine and famotidine, have much more rapid onset of effect, and antacids, e.g., TUMS, Rolaids, Mylanta, etc., neutralize acid instantly. The choice of medications should match the patient’s pattern of medication use and the frequency of symptoms, i.e., antacids only for occasional heartburn, PPI for chronic, documented esophagitis.

Compounded omeprazole (and lansoprazole) suspensions are not very stable chemically, and significant degradation occurs over time, even if they are stored in the refrigerator. They also should not be taken with food, and should be given separately from meals or feedings. Omeprazole suspension is compounded with sodium bicarbonate, as the medication is exquisitely sensitive to inactivation by gastric acid. Mixing with food will likely increase the probability that the medication will get inactivated prior to absorption in the duodenum.

For children who take omeprazole in granule form, the granule content in the omeprazole capsules must be mixed in a mildly acidic food such as applesauce or yogurt. These granules are formulated to resist dissolution in acid, and to dissolve in the alkaline environment of the duodenum. Mixing the granules in non-acidic food will cause the granules to dissolve prematurely, resulting in inactivation in the stomach. The child also must swallow the granules without chewing or crushing them, for the same reason.

The medication seems to help, but only partially

The medication dosage may be too low. If the dosage happens to be on the lower end of the range, try increasing the dosage. If the patient is on an H2RA class medication, consider trying a PPI, but not indefinitely. If increasing the dosage or changing to a stronger medication has no effect, acid may not necessarily be the problem.

The marginal treatment effect observed is a placebo effect. This is probably the most likely situation.

It’s not acid reflux, and it’s not gastritis. It is common to try acid reducers and/or antacids for upper digestive symptoms such as nausea, early satiety, regurgitation, vomiting, stomachaches above the umbilicus, etc. However, their symptoms may be quite non-specific. Gas bloat may cause nausea and early satiety. Biliary disease may cause nausea, vomiting, and abdominal pain above the umbilicus. Lower GI causes of abdominal pain can also cause pain above the umbilicus, though not exactly in the epigastric area. Epigastric abdominal pain refers to pain just below the rib cage, or just below the nipple line, not one inch above the umbilicus. The following are the most common conditions, approximately in descending order of frequency, that may look like GERD or gastritis, but are not:

- Lower GI symptoms – just because the pain is above the umbilicus does not necessarily mean that it’s a stomach problem, especially if the pain feels like cramps, bloating, and is associated with diarrhea or constipation.

- Functional dyspepsia – this is also often known as non-ulcer dyspepsia. Pain is not due to any actual mucosal disease, but due to excessive visceral sensitivity to movements and distension in the upper digestive tract. It is not an acid problem. Anxiety (usually in the child, but often equally in the parents) is a major exacerbating factor. Look for probable secondary gains (school avoidance, siding with one parent in case of parental divorce/separation/custody issues, etc.)

- It’s a teenage thing – a large number of teens are referred for complaints of nausea, and sometimes vomiting, that occurs only in the mornings. This usually happens on school days, and if they sleep in on weekends, they wake up feeling fine. Complaints usually subside by late morning or lunch time. Investigations for specific disease usually turn out fruitless.

- Gallstones, other gallbladder/biliary problems, and something wrong with the pancreas – pain may not always be in the right upper quadrant. Sometimes it can be epigastric in location.

- Rumination – this can be done either with children regurgitating volitionally (e.g., an autistic child regurgitating his favorite meal of pizza in order to savor the experience longer, until it no longer tastes good), or involuntarily. In either case, regurgitation is not due to problems with the esophagus, but because of abnormal abdominal muscle contractions that force the food up.

- Inflammatory bowel disease – Crohn’s disease can present with either upper or lower GI symptoms.

- Celiac disease – pediatric gastroenterologists don’t see much tuberculosis, syphilis or sarcoidosis, so celiac disease is the great imitator in their place. Celiac disease can sometimes be a dead ringer for erosive esophagitis symptom-wise, except that on endoscopy, the esophagus looks normal, but the duodenum….

- Pregnancy – this writer has been fooled by this, more than once.

- Helicobacter pylori infection. This is a fairly complex and controversial subject, and deserves a separate discussion by itself in the future.

In view of the above, a reasonable diagnostic approach, in addition to getting a good history and physical examination, may include the following laboratory and imaging studies: CBC with differential, ESR, C-reactive protein, serum lipase, ALT, creatinine, celiac disease panel, stool H. pylori antigen, and abdominal ultrasound. Consider a urine pregnancy test in appropriate situations.

These studies should be ordered based on one’s clinical impressions and suspicions of specific concerns. They do not need to be ordered en bloc in every case.

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The Child Who Won't Swallow Food...Is It Globus, Or Is It an Obstruction? (December 2017)

Dysphagia is a common reason for pediatric GI referrals, and the differential diagnosis for dysphagia can be pretty daunting initially. Could this be due to a foreign body, an esophageal stricture, esophageal dysmotility, a neuromuscular disorder, a brain tumor, an eating disorder, achalasia, or globus? Of these, globus, also often known as globus sensation or the somewhat politically incorrect expression, globus hystericus, is the condition that should be readily recognizable by the primary care provider, and when properly approached, can be easily and satisfactorily managed without much diagnostic workup.

The child with globus sensation typically presents with a somewhat acute onset of difficulty swallowing. This might have initially been triggered by a choking incident, where the child’s throat had an awkward encounter with a small piece of bone, an inadequately chewed piece of meat or hot dog, or a stringy piece of vegetable. Occasionally the trigger is more obvious, as the child accidentally swallowed a coin that has passed through the digestive tract without intervention (coins that get stuck is a different story). Rarely, an actual physical trigger event is not identified. When asked to describe the sensation, the child describes a feeling that something is stuck in the throat when swallowing, and he/she points to the neck as the location of the discomfort. The child does not drool, is able to swallow liquids, has normal voice quality, but often makes hard gulping motions when swallowing saliva during the visit. The throat examination is normal. If you choose to perform a throat culture (despite the pharynx looking normal), the child will gag and sputter for half an hour before a satisfactory swipe at the pharynx is accomplished.

The parents often will express concern that the child has been losing weight, and that he/she refuses to eat any solid food, but drinks water, soup, smoothies, shakes, etc. Everyone in the family is convinced that the child has an obstruction somewhere inside. The child appears very anxious. Everyone is expecting some test to identify the cause of the problem, but all tests that have been done so far, which might include X-rays and a direct laryngoscopy, were normal.

The above is a reasonably accurate composite of a child with globus sensation in the outpatient setting. But, what exactly is globus? A good explanation that I often use is to have one think of a person who is unable to swallow pills. This person, whether a child or adult, looks at the small tablet with trepidation, and when given no choice but to try and swallow the pill, puts it in the mouth with a gulp of water, but the pill simply does not get past the throat after multiple tries. On the other hand, this person would normally have no trouble swallowing large mouthfuls of food, even if not well chewed, without a second thought. In contrast, a toddler can easily get a coin past the pharynx (but not necessarily past the lower esophageal sphincter…do not try this with your own child!), and I have met a 4-year-old child with Down syndrome whose mother had taught to swallow large pills without difficulty. Globus is basically the exaggerated sensation in the throat you get when you are afraid to swallow something. We normally have sensations in the throat when we swallow, but we don’t pay much attention to it. However, when we become anxious and pay greater attention to the sensation, it becomes intensified and distressing, and we think that we are choking.

When should we worry that the dysphagia is something other than globus sensation? Inability to swallow even liquids and drooling are worrisome, as these suggest the presence of either esophageal obstruction (foreign body, stricture) or dysmotility (achalasia). Complaints of something stuck below the neck, i.e., at chest level, suggests a high probability of esophageal disease. Vomiting and unusual respiratory symptoms also are not normal findings in globus, and suggest the presence of other concerns.

If the child presents with typical globus-like history and findings, it is best to explain to the family at the very outset that this is likely the cause of the child’s swallowing difficulty, and that there is no need for any additional diagnostic testing. It is important to reassure that adequate nutrition can be achieved with liquid supplements on a temporary basis, and that children with globus sensations invariably will return to their normal eating behavior, though it may take up to a few months before they experience a full recovery. As a pediatric gastroenterologist, I try to discourage upper GI endoscopies (EGD), as this likely will exacerbate the child’s anxiety, and potentially prolong recovery. Finally, it is important to counsel the family members to acknowledge, but avoid excessive attention to the child’s complaints, as perceived anxiety in the family members will tend to worsen the child’s own anxiety.

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The Child Who Can't Stop Burping (A Peds GI Airy Tale) (November 2018)

Once upon a time during the Second Millennium, Dr. Glenn Duh was a pediatric GI fellow (he had dark hair then) who was rounding with his mentor, Dr. Frank R. Sinatra (yes, that’s his real name), at the LAC+USC Medical Center. They received a consultation request to see an adolescent boy who was admitted to the general pediatrics ward for excessive burping. The two doctors looked at each other incredulously, thinking that this couldn’t be true, and if the boy was truly admitted for burping, this would have been the most ridiculous admitting diagnosis at a county hospital. Yes, the world-class doctors here treated gunshot wounds, spleen lacerations and kids who burped out of control.

Ever prepared to take on a new challenge, Dr. Duh followed Dr. Sinatra to see the patient, realizing that he had nary a clue what could be going on. They arrived at the patient’s room before Dr. Duh could even come up with a differential diagnosis, and encountered an overweight teenage boy sitting at the edge of the bed, burping. Dr. Sinatra briefly introduced themselves, appearing genuinely concerned and serious, and asked the patient to describe the reason why he was in the hospital.

Doct..burrrrrp…tor, burrrrrp I can’t burrrrrrp stop burrrrrrrrrrp burp…burrrrrrrrp…ping. Burrrrrrp…can...burrrrrrrp you burrrrrrrrp help me…burrrrrrrrrp?

OK, perhaps the admission wasn’t all that ridiculous after all. This boy was suffering, and needed help. Dr. Sinatra asked him a few more questions, but the answers were provided laboriously, with words occasionally escaping between belches. The kid was at the verge of exhaustion, having been unable to sleep for a couple of days. Would the child survive? Could the patient in the adjacent bed get any sleep? Stay tuned for the conclusion of this hyperaerated saga….

Excessive burping is a common complaint, and most believe that it’s because they have too much gas inside their stomachs. However, a gassy stomach is not an adequate answer for someone who burps out of control. Consider the person who can burp the alphabet. He/she can repeatedly let out throaty belches while sounding out all the letters from A to Z. The problem is that the stomach simply does not have enough gas for someone to belch that many times. If one considers the analogy of someone sitting on a Whoopee Cushion, how many times can you keep sitting on it without reloading before it doesn’t fart any longer? The truth is that one’s stomach doesn’t hold that much air, so the only way that one can belch repeatedly is by aerophagia, that is, swallowing air, whether consciously or subconsciously. Physiological studies have demonstrated that many individuals who belch excessively swallow air immediately before burping, and the air is expelled out of the esophagus before it even travels to the stomach. Unfortunately, the underlying causes for the aerophagia and repeated burps are often unknown. For a lack of better explanations, we often surmise that the affected individuals may have GERD, and that the belching might be their response to discomfort from esophageal irritation. It is possible that a trial course of acid reducers may help, though it is difficult to determine whether the observed response is due to the placebo effect or successful treatment of an acid peptic disorder. For others, the problem may be that of anxiety, though the anxiety is sometimes the result of excessive burping, as one may start to become self-conscious and embarrassed about the untimely sound effects.

So, how do we treat excessive burping? For those with frequent, but not non-stop burping, it helps to suggest avoidance of carbonated beverages, chewing gum, sucking on hard candies, and slurping drinks with straws. Additional advice for adults often includes avoiding eating with the mouth open and making sure that dentures fit properly, though dentures aren’t commonly encountered in pediatrics. The idea behind such advice is that if you don’t fill up the stomach with air, you won’t burp as much. As for those who burp much more excessively, who most likely are actively gulping air, knowingly or unknowingly, I often recommend that they practice abdominal breathing techniques, and refer to a YouTube video of The Karate Kid (1984), where Mr. Miyagi teaches Daniel-san how to breathe properly. It is not possible to swallow air while doing abdominal breathing exercises. Proper assessment and management of anxiety disorder may also be appropriate in certain settings.

As this discussion nears its end, let’s return to the case of the boy who was hospitalized for burping out control. Dr. Sinatra looked at the boy, and asked him to open his mouth wide and stick his tongue out. The burping stopped abruptly and instantly, and he did not burp as long as he kept his mouth open. Appearing uncomfortable, the boy signaled with his hands, asking whether he could close his mouth again. After Dr. Sinatra gave him permission to do so, he took a hard swallow, and then let out a loud belch. No swallow, no filling up the Whoopee Cushion inside the chest. It was as simple as that.

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Let's Chew on This...Rumination Syndrome, That Is (March 2019)

I once saw a teen girl for a second opinion because of recurrent vomiting that failed to respond to treatment. She was tall, slender, quite attractive, and a former state beauty pageant winner for her age group. She did not have issues with excessive regurgitation during infancy, and seemed reasonably normal during her early childhood and grade school years, but vomiting started insidiously during adolescence. Although she did not complain of much nausea, she would vomit almost immediately after she ate or drank anything, with one notable exception - for reasons that defied explanation, the girl could always manage to drink a certain variety of smoothie from Jamba Juice (and only that specific flavor) without vomiting. Her vomiting occurred so frequently that she developed electrolyte imbalances, and required daily potassium