- Pediatric Gastroenterology
- Inflammatory Bowel Disease
- fecal microbiota transplant
- very early onset IBD
- Dietary therapy in IBD
- Eosinophilic disorders of the gastrointestinal tract
Clinical Professor, Pediatrics - Gastroenterology
Director of the Inflammatory Disease Service, Children’s Mercy Kansas City (2016 - 2020)
Director, Endoscopy Center, UPMC Children’s Hospital of Pittsburgh (2014 - 2016)
Medical Director, Infusion Center, UPMC Children’s Hospital of Pittsburgh (2013 - 2016)
Medical Director, Gastroenterology Inpatient Unit, UPMC Children’s Hospital of Pittsburgh (2012 - 2016)
Honors & Awards
Award for Commitment and Service (ACES), UPMC, Pittsburgh, PA (2010)
Outstanding Achievement in Patient Care, UPMC Children’s Hospital of Pittsburgh (July 2004)
Advanced Research Training Award, American Digestive Health Foundation (July 1996-June 1998)
Boards, Advisory Committees, Professional Organizations
Professional member, Crohn’s & Colitis Foundation (2006 - Present)
member, North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (2002 - Present)
Member, American Gastroenterological Association (2000 - Present)
Life Member, Indian Academy of Pediatrics (1988 - Present)
Board Certification: American Board of Pediatrics, Pediatric Gastroenterology (1999)
Fellowship: Washington University Gastroenterology Fellowship (1998) MO
Residency: University of Connecticut Pediatric Residency (1993) CT
Medical Education: Lady Hardinge Medical College (1985) India
Anemia in Children With Inflammatory Bowel Disease: A Position Paper by the IBD Committee of the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition.
Journal of pediatric gastroenterology and nutrition
2020; 71 (4): 563-582
Anemia is one of the most common extraintestinal manifestations of inflammatory bowel disease (IBD). It can be asymptomatic or associated with nonspecific symptoms, such as irritability, headaches, fatigue, dizziness, and anorexia. In IBD patients, the etiology of anemia is often multifactorial. Various causes include iron deficiency, anemia of inflammation and chronic disease, vitamin deficiencies, hemolysis, or myelosuppressive effect of drugs. Anemia and iron deficiency in these patients may be underestimated because of their insidious onset, lack of standardized screening practices, and possibly underappreciation that treatment of anemia is also required when treating IBD. Practitioners may hesitate to use oral preparations because of their intolerance whereas intravenous preparations are underutilized because of fear of adverse events, availability, and cost. Several publications in recent years have documented the safety and comparative efficacy of various intravenous preparations. This article reviews management of anemia in children with IBD, including diagnosis, etiopathogenesis, evaluation of a patient, protocol to screen and monitor patients for early detection and response to therapy, treatment including parenteral iron therapy, and newer approaches in management of anemia of chronic disease. This report has been compiled by a group of pediatric gastroenterologists serving on the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) IBD committee, in collaboration with a pediatric hematologist, pharmacist, and a registered dietician who specializes in pediatric IBD (IBD Anemia Working Group), after an extensive review of the current literature. The purpose of this review is to raise awareness of under-diagnosis of anemia in children with IBD and make recommendations for screening, testing, and treatment in this population.
View details for DOI 10.1097/MPG.0000000000002885
View details for PubMedID 32947565
Safety, Clinical Response, and Microbiome Findings Following Fecal Microbiota Transplant in Children With Inflammatory Bowel Disease.
Inflammatory bowel diseases
2018; 24 (2): 410-421
The role of fecal microbiota transplant (FMT) in the treatment of pediatric inflammatory bowel disease (IBD) is unknown. The aims of this study were to assess safety, clinical response, and gut microbiome alterations in children with Crohn's disease (CD), ulcerative colitis (UC), or indeterminate colitis (IC).In this open-label, single-center prospective trial, patients with IBD refractory to medical therapy underwent a single FMT by upper and lower endoscopy. Adverse events, clinical response, gut microbiome, and biomarkers were assessed at baseline, 1 week, 1 month, and 6 months following FMT.Twenty-one subjects were analyzed, with a median age of 12 years, of whom 57% and 28% demonstrated clinical response at 1 and 6 months post-FMT, respectively. Two CD patients were in remission at 6 months. Adverse events attributable to FMT were mild to moderate and self-limited. Patients prior to FMT showed decreased species diversity and significant microbiome compositional differences characterized by increased Enterobacteriaceae, Enterococcus, Haemophilus, and Fusobacterium compared with donors and demonstrated increased species diversity at 30 days post-FMT. At 6 months, these changes shifted toward baseline. Clinical responders had a higher relative abundance of Fusobacterium and a lower diversity at baseline, as well as a greater shift toward donor-like microbiome after FMT compared with nonresponders.A single FMT is relatively safe and can result in a short-term response in young patients with active IBD. Responders possessed increased Fusobacterium prior to FMT and demonstrated more significant microbiome changes compared with nonresponders after FMT. Microbiome characteristics may help in predicting response.
View details for DOI 10.1093/ibd/izx035
View details for PubMedID 29361092
Personalized Research on Diet in Ulcerative Colitis and Crohn's Disease (PRODUCE): A Series of N-of-1 Diet Trials.
The American journal of gastroenterology
OBJECTIVES: Evidence about Specific Carbohydrate Diet (SCD) for inflammatory bowel disease (IBD) is limited. We conducted 54 single-subject, double-crossover N-of-1 trials comparing SCD to a modified SCD (MSCD) and comparing each to the participant's baseline, usual diet (UD).METHODS: Across 19 sites, we recruited patients 7-18 years with IBD and active inflammation. Following a 2-week baseline (UD), patients were randomized to one of two sequences of four alternating 8-week SCD and MSCD periods. Outcomes included fecal calprotectin and patient-reported symptoms. We report posterior probabilities from Bayesian models comparing diets.RESULTS: Twenty-one (39%) participants completed the trial, 9 (17%) completed a single crossover, and 24 (44%) withdrew. Withdrawal or early completion occurred commonly (lack of response (n=11), adverse events (n=11) and not desiring to continue (n=6)). SCD and MSCD performed similarly for most individuals. On average, there was <1% probability of a clinically meaningful difference in IBD symptoms between SCD and MSCD. The average treatment difference was -0.3 (95% CrI -1.2, 0.75). There was no significant difference in the ratio of fecal calprotectin geometric means comparing SCD and MSCD [0.77 (95% CrI 0.51, 1.10)]. Some individuals had improvement in symptoms and fecal calprotectin compared to their UD, while others did not.CONCLUSIONS: SCD and MSCD did not consistently improve symptoms or inflammation, although some individuals may have benefited. However, there are inherent difficulties in examining dietary changes that complicate study design and ultimately conclusions regarding effectiveness.
View details for DOI 10.14309/ajg.0000000000001800
View details for PubMedID 35442220
When It Is Not Inflammatory Bowel Disease: IBD Mimics Presented at IBD Live
LIPPINCOTT WILLIAMS & WILKINS. 2021: S1377
View details for Web of Science ID 000717526105464
Current Challenges in Fecal Microbiota Transplantation for Clostridioides difficile Infection in Children.
The American journal of gastroenterology
INTRODUCTION: The impact of the 2019 US Food and Drug Administration safety alert involving transmission of multidrug resistant organisms through fecal microbiota transplantation (FMT), and the COVID-19 pandemic on the use of FMT in children, is unknown.METHODS: A survey of pediatric gastroenterologists performing FMT for Clostridioides difficile infection was conducted.RESULTS: Of 36 respondents, 17 (47%) and 30 (83%) changed their FMT practices related to the US Food and Drug Administration safety alert and COVID-19 pandemic, respectively, with 22 (61%) of programs halted.DISCUSSION: The US Food and Drug Administration safety alert and COVID-19 pandemic have substantially influenced the availability and access of FMT for children.
View details for DOI 10.14309/ajg.0000000000001350
View details for PubMedID 34140459
- A Case of Epinephrin-associated Refractory Hypotension Secondary to Lactic Acidosis. Inflammatory bowel diseases 2021
Natural History of Very Early Onset Inflammatory Bowel Disease in North America: A Retrospective Cohort Study.
Inflammatory bowel diseases
The incidence of very early onset inflammatory bowel disease (VEOIBD) is increasing, yet the phenotype and natural history of VEOIBD are not well described.We performed a retrospective cohort study of patients diagnosed with VEOIBD (6 years of age and younger) between 2008 and 2013 at 25 North American centers. Eligible patients at each center were randomly selected for chart review. We abstracted data at diagnosis and at 1, 3, and 5 years after diagnosis. We compared the clinical features and outcomes with VEOIBD diagnosed younger than 3 years of age with children diagnosed with VEOIBD at age 3 to 6 years.The study population included 269 children (105 [39%] Crohn's disease, 106 [39%] ulcerative colitis, and 58 [22%] IBD unclassified). The median age of diagnosis was 4.2 years (interquartile range 2.9-5.2). Most (94%) Crohn's disease patients had inflammatory disease behavior (B1). Isolated colitis (L2) was the most common disease location (70% of children diagnosed younger than 3 years vs 43% of children diagnosed 3 years and older; P = 0.10). By the end of follow-up, stricturing/penetrating occurred in 7 (6.6%) children. The risk of any bowel surgery in Crohn's disease was 3% by 1 year, 12% by 3 years, and 15% by 5 years and did not differ by age at diagnosis. Most ulcerative colitis patients had pancolitis (57% of children diagnosed younger than 3 years vs 45% of children diagnosed 3 years and older; P = 0.18). The risk of colectomy in ulcerative colitis/IBD unclassified was 0% by 1 year, 3% by 3 years, and 14% by 5 years and did not differ by age of diagnosis.Very early onset inflammatory bowel disease has a distinct phenotype with predominantly colonic involvement and infrequent stricturing/penetrating disease. The cumulative risk of bowel surgery in children with VEOIBD was approximately 14%-15% by 5 years. These data can be used to provide anticipatory guidance in this emerging patient population.
View details for DOI 10.1093/ibd/izaa080
View details for PubMedID 32386060
Liver Enzyme Elevations Within 3 Months of Diagnosis of Inflammatory Bowel Disease and Likelihood of Liver Disease
JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION
2014; 59 (3): 321-323
Inflammatory bowel disease-associated liver diseases (IBD-LDs) include autoimmune hepatitis (AIH), primary sclerosing cholangitis (PSC), and an overlap syndrome. Prospective unbiased multicenter data regarding the frequency of IBD-LD in patients with pediatric inflammatory bowel disease (IBD) are lacking. We examined early alanine aminotransferase (ALT) and γ-glutamyl transpeptidase (GGT) elevations in children diagnosed as having IBD and assessed the likelihood of IBD-LD.Data collected from the prospective observational Pediatric Inflammatory Bowel Disease Collaborative Research Group Registry enrolling children of age <16 years within 30 days of diagnosis. AIH, PSC, and overlap syndrome were diagnosed using local institutional criteria.A total of 1569 subjects had liver enzymes available. Of the total, 757 had both ALT and GGT, 800 had ALT only (no GGT), and 12 had GGT only (no ALT). Overall, 29 of 1569 patients (1.8%) had IBD-LD. IBD-LD was diagnosed in 1 of 661 (0.15%) of patients with both ALT and GGT ≤ 50 IU/L compared with 21 of 42 (50%) of patients with both ALT and GGT > 50 (odds ratio 660, P < 0.0001). Of the 29 patients with IBD-LD, 21 had PSC, 2 had AIH, and 6 had overlap syndrome. IBD-LD was more common in patients with ulcerative colitis and IBD-unclassified (indeterminate colitis) than in those with Crohn disease (4% vs 0.8%, respectively, P < 0.001).Elevation of both ALT and GGT within 90 days after the diagnosis of IBD is associated with a markedly increased likelihood of IBD-LD. Both ALT and GGT levels should be measured in all of the pediatric patients newly diagnosed as having IBD.
View details for DOI 10.1097/MPG.0000000000000409
View details for Web of Science ID 000341080700012
View details for PubMedID 24796799