Gastroenterology Concerns in Children with Rohit Josyabhatla, M.D.

Rohit Josyabhatla, M.D., a pediatric gastroenterologist, answers questions about common gastroenterology concerns in children. These include swallowing harmful objects such as button batteries, reflux, fatty liver disease, poop and more.

Q: Tell us a little bit about what your specialty. What does a gastroenterologist do?

A: A gastroenterologist is a doctor who takes care of diseases that are associated with the gastrointestinal system, which extends from the mouth all the way down to the large intestine and the colon. The liver and the pancreas are part of this system. We also treat children who have problems with nutrition. A gastroenterologist may do a procedure called an endoscopy to diagnose and treat conditions.

Q: What are some of the most common gastrointestinal conditions that you see in children?

A: Some of the more common conditions are reflux, constipation and chronic abdominal pain.

We also take care of children who have feeding problems, which may require alternative ways to provide nutrition.

Other conditions may be allergy related, such as celiac disease, a milk-protein allergy or eosinophilic esophagitis. We treat children who have chronic inflammatory conditions such as inflammatory bowel disease. A common liver disease that we see is fatty liver disease.

We also take care of some emergent conditions like upper gastrointestinal bleeding, swallowed foreign objects and food impaction.

Q: You mentioned fatty liver disease in children. What is it, and is this on the rise?

A: Fatty liver disease is a condition where there is an accumulation of fat in the liver. It used to be an adult disease, but with the rising presence of obesity in children, it isincreasingly common in children.

Oftentimes, it’s seen in association with conditions like diabetes and hypertension, but in  kids, it can present by itself. When caught early, it is a reversible condition. When children exercise and have a healthy diet, the liver tends to go back to normal. But left untreated, it can sometimes lead to long-term inflammation and then problems with scarring like cirrhosis.

Q: Talk about the signs and symptoms of reflux. What should parents watch for?

A: Reflux is an extremely common condition that we most often see in children who are under the age of 1 year. Reflux is different from reflux disease. Reflux is just the process of food coming up from your stomach into the esophagus. When that comes up all the way, it’s called regurgitation. If that causes inflammation or irritation in the esophagus, it’s called gastroesophageal reflux disease.

A majority of the infants who have reflux do not have problems. They are sometimes called “happy spitters” because they tend to reflux a lot throughout the day, but that doesn’t interfere with their ability to eat or their eagerness to feed. They continue to gain weight. Most of them are fine by 6-8 months, and most often reflux completely subsides by the time they are a year to a year-and-a-half.

In some cases, reflux could be severe enough to lead to severe irritability associated with eating or irritation in the esophagus. It can reach a point where the infants start to avoid feeding, and then they lose weight. In those situations, we treat reflux more carefully.

Initially, simple measures that can be instituted are positional therapy, where we ask the parents to hold the child up after feeding. Sometimes, if there’s tobacco exposure in the household, we educate parents about trying to eliminate that. Other options that we use are things like thickening the milk, using either oat cereal or commercial thickeners.

Rarely, reflux could be secondary to a kind of milk protein allergy, and in those situations, using an alternate formula, or a special formula can help decrease the frequency of reflux.

Kids who have reflux to a point where they’re losing weight could indicate genetic or metabolic conditions. Sometimes conditions that can cause increased pressure in your brain could cause reflux and vomiting, so when kids have prolonged periods of reflux and they have problems with weight gain, then we evaluate for other conditions  as well.

Q: So reflux may be something that infants will sort of outgrow, but it could be a sign of a more major issue. What steps should parents take if they notice reflux symptoms?

A: I think as a first step they should definitely talk to their pediatrician so that they can assess the extent and severity of the reflux. And then, based on how severe the symptoms are, and particularly if it starts to interfere with the child’s weight gain and their growth and developmental milestones, then it needs to be looked at more carefully. If it is not gastrointestinal-related, then you try to identify that and treat it. If it is gastrointestinal, you try to see if this is a condition that can be treated medically or if it requires a surgical fix. And that’s where we come in.

Q: Another condition that you treat is EOE. What is EOE, and what are the symptoms?

A: EOE is an abbreviation for eosinophilic esophagitis. Eosinophils are a particular type of white blood cell that participates in allergy-mediated reactions. Esophagitis is a term that refers to inflammation in the food pipe. So in EOE, these eosinophils  line the esophagus, and cause inflammation, leading to problems with the way the esophagus functions.

This condition was not known before the 1990s. As awareness has increased about this condition, we are recognizing it and looking for it. And with that, we’ve found that the prevalence has also increased.

This is a condition where the current understanding is that there is some kind of a trigger, which is either in the food or in the air, that tends to localize in the upper part of the esophagus or through the esophagus, which then causes this immune-mediated reaction.

This condition tends to go along with other allergy-mediated conditions, like asthma, eczema and seasonal allergies. For some reason, it has a slightly higher preponderance in males as compared to females, and it’s seen in all age groups.

The way EOE presents varies based on the age of the child. Younger kids typically have vomiting and difficulty gaining weight. Older kids tend to present with pain in the belly, sometimes with reflux-like symptoms, and occasionally they may have difficulty with swallowing.

Parents may note that kids are taking more time to chew on solids. Sometimes they may notice that kids are drinking more water when they are eating to push things along. And rarely, kids may present directly to the emergency room with a food impaction, where particularly dry meats like a piece of steak, or a pork chop or a hot dog may get stuck in the esophagus and not move, so they may start drooling. That’s one of the common presentations of this condition as well.

Q: And you say there’s some indication that EOE is related to allergies in food or something in the air. So, if your child does have allergies, is that something that parents might watch for?

A: Yes, definitely. I think if someone has asthma or eczema and starts to have these symptoms, then they should be closely monitored for worsening signs and symptoms. And certainly, if they have a clinical spectrum that’s consistent with EOE, then their pediatrician should refer them to a gastroenterologist. Sometimes these patients are referred to us even by a pulmonologist, or lung doctor, who see that kids who have asthma may start complaining about difficulty with swallowing. We diagnose EOE by doing testing.

Q: And what is the treatment for EOE?

A: The only way to diagnose this condition is by endoscopy. The inflammation is limited to the lining of the esophagus, so blood tests and breath tests and other forms of imaging like an X-ray may not be adequate in diagnosing this condition. We go in with an endoscope and also do biopsies to determine the level of the eosinophils before making a diagnosis.

Once a diagnosis is made, we work with our allergy colleagues to see if we can identify potential food allergens. If we do find an allergen, then one strategy is to try to eliminate common food allergens.

Other options will include use of long-term antacids, like proton-pump inhibitors, or oral steroids in the form of a slurry. The steroid coats the lining of the esophagus, and then acts locally to control the inflammation.

Q: What are some of the other conditions that you see, like celiac? A lot of parents think their children shouldn’t be eating wheat. Are those concerns accurate? What kinds of other things should parents know in terms of common diseases or conditions?

A: Celiac disease is definitely a very common condition. It is a kind of sensitivity, which is immune-mediated, where adults as well as children  mount an immune reaction to protein, which is present in gluten. The gluten is in wheat, rye or barley.

This immune reaction typically tends to affect the small intestine and then cause symptoms of gastrointestinal disease. Sometimes symptoms are not overt, but it can cause nutritional deficiencies, which then eventually lead to symptoms.

There are blood tests to screen for celiac disease that serve as an initial test to at least capture some of these patients. Most patients will require an endoscopy to confirm the diagnosis. Celiac disease is present at a rate of 1 in every 100 individuals in the U.S., and I think that’s why we have more options available in the stores when it comes to gluten-free products.

There are some individuals who are at higher risk of celiac disease, such as patients who have early-onset diabetes or other autoimmune conditions. Patients who have a family history of celiac disease need to be closely screened, particularly if they have any GI symptoms.

Q: What are the symptoms of celiac disease?

A: Celiac can present in myriad ways. Oftentimes it presents with diarrhea, abdominal pain and bloating, but sometimes the symptoms are completely unrelated to the GI tract. It can present with joint pains and headaches, which are then diagnosed as celiac disease.

When there is a family history, and when patients are at a higher risk with coexisting autoimmune diseases, then you certainly want to screen for celiac disease. Others who have GI symptoms should be screened for celiac.

Q: We’ve touched on some of the conditions and diseases that you deal with. It does sound like these conditions can be complicated if they’re related to allergies or maybe smoking in the home or asthma. What other kinds of things should parents know about gastrointestinal problems, and when should they be concerned?

A: I think symptoms that start to interfere with quality of life, particularly if you have chronic abdominal pain, if you have diarrhea that’s starting to interfere with your day-to-day life, signs of bloody diarrhea and vomiting, particularly if you see blood in the vomit, these are conditions that should prompt you to immediately seek an opinion or care from a gastroenterologist. Other conditions where you should seek care are things like weight loss or if children have difficulty  gaining weight over a long period of time.

Q: You mentioned that swallowing foreign objects can be extremely dangerous. What should parents do if their child swallows an object or if they suspect their child has swallowed something?

A: Button batteries, coins and caustic objects like dishwasher pods or washing machine pods need to be carefully locked away and kept out of reach of children. Button batteries are about the size of a quarter, and your esophagus is about the same size, so the button battery can get lodged. And when it is stuck, it will discharge its current and cause damage to that area. The longer it stays, the higher the chance the damage can be severe. Button batteries and caustic substances cause damage and corrosion very quickly. It’s important to seek care right away.

The best option is prevention. Make sure that button batteries are either kept in locked cabinets, or if they’re in toys, make sure that the batteries are not easy to access. Caustic objects should be locked in cabinets and kept out of reach of children as well.

If kids do swallow one of these objects, immediately take them to the emergency room to be treated.

Q: Parents of infants are concerned about poop. When should we worry?  If we’re noticing something, what should we be looking for?

A: That’s one of the most common reasons for patients to come in and see us. The majority of the time, constipation seems to be unrelated to a clear cause, where we do some tests, we do imaging, and we don’t really find out a clear cause.

And most of these situations get better with either changes to diet such as increasing fruit and vegetable intake or fiber intake. Sometimes using a stool softener on a regular basis helps, and sometimes just having a regular toilet schedule seems to help. Sometimes changes in the home setting or school setting and stress can lead to constipation, so addressing that often helps take care symptoms.

But when constipation starts to interfere with the child’s diet or causes pain and bloating or it is so severe that it leads to recurring vomiting and decreased appetite, and then difficulty with gaining weight, those would all be indications to seek medical care.

In a fraction of patients, constipation could be related to obstruction, so that need to be carefully evaluated. Vomiting, particularly green-colored bile, and fever can sometimes can tell us that there’s an obstruction, so imaging can help. Sometimes that might require a surgical fix. Rarely, problems with the spinal cord can cause a problem with the way the nerves are distributed in the intestine, which can lead to constipation. Kids who have problems with urination can also have problems with constipation. Each condition needs to be looked at to see how it can be treated.

Dr. Rohit Josyabhatla is a fellowship-trained pediatric gastroenterologist with Warren Clinic and the Children’s Hospital at Saint Francis. His residency was at Rutgers New Jersey Medical School, and his fellowship was at the University of Texas Health Science Center. He specializes in the diagnosis, treatment and prevention of a wide range of gastrointestinal conditions related to the digestive system, liver, pancreas and nutrition in infants, children and teens.