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New Device Makes Esophageal Endoscopy Faster and Safer for Patients with EoE

Dr. Nicholas CaJacob performs a transnasal endoscopy on a patient using a new endoscope manufactured by EvoEndo.

Children’s of Alabama is among the first 10 pediatric medical centers in the nation to use a new endoscope that can make transnasal endoscopy (TNE) faster and easier for some patients with eosinophilic esophagitis (EoE). The device, manufactured by EvoEndo, was approved by the U.S. Food and Drug Administration last year. Children’s began using it in June 2023.

EoE is a chronic immune-mediated inflammatory disease of the esophagus resulting in symptoms and signs of esophageal dysfunction. Physicians use endoscopy every two to three months to biopsy tissue to evaluate treatment success. The new endoscope, which is inserted through the nose into the esophagus, requires no general anesthesia, just an anesthetic spray to numb the nasal passages. Patients remain awake during the procedure and need to fast only for two hours prior. Virtual reality goggles keep patient’s focus off the procedure, while a family member can be in the room observing and getting updates in real time. Children’s pediatric gastroenterologist Diana Montoya Melo, M.D., says it’s a potential game changer for patients and their families.

Montoya Melo and Nicholas CaJacob, M.D., also a pediatric gastroenterologist at Children’s, each perform about 10 EoE endoscopic procedures a week.Previously, the standard endoscopic procedure involved inserting the endoscope through the mouth into the esophagus. That method requires general anesthesia and intubation, fasting for at least six hours, a very early arrival at the hospital, IV insertion and about an hour in the recovery room after the 10-minute procedure—all of which puts a tremendous burden on the family and increases costs and the risk of potentially serious side effects.

With the new device, transnasal endoscopies takes about 15 minutes, and Montoya Melo expects the endoscopy team to be able to complete them even faster as they gain more experience. Patients also are able to leave right after the procedure. “We don’t have to monitor anything,” she said. “We’re getting the same results but in a safer, more convenient way for families and patients.”

An added bonus, Montoya Melo says, is that the endoscope is disposable. “Families like to know that it hasn’t been used on anybody before.” This also expedites the procedure because doctors don’t have to process or reprocess the equipment. “We just take it out of the box and use it,” she said. The device is approved for children 5 and older, although most centers limit its use to those 10 and older, she says.

TNE isn’t for everyone. “There are some children who are more anxious, or they will not tolerate the endoscope going through the nose,” Montoya Melo said. “This is mostly for patients and families who are interested in a different approach.” One way to know if a child is a good candidate? “We ask how they tolerated their COVID test,” she said. “And we tell them it won’t feel any worse than that.”


Gupta Aims to Make Children’s a “Destination of Choice” for Gastroenterology

Dr. Sandeep Gupta joined Children’s of Alabama as chief of Pediatric Gastroenterology, Hepatology and Nutrition in April 2023.

Ask Sandeep Gupta, M.D., Children’s of Alabama’s new chief of the Division of Pediatric Gastroenterology, Hepatology and Nutrition, about his goals, and he answers immediately: “To drive positive change and empower people to rise. At the end of the day, their success is our collective success.”

To that end, he said, he wants to bring “positive energy and collaborative change so as to make everyone a winner.” Without that, he said, the department can’t do its most important job: serving patients.

Gupta came to Children’s of Alabama in April after nearly 30 years at Indiana University School of Medicine and Riley Hospital for Children in Indianapolis. He brings leadership experience to Children’s, including roles as the editor-in-chief of the Journal of Pediatric Gastroenterology and Nutrition and the vice-chair of the Pediatric Growth and Development Biology Section of the American Gastroenterological Association Institute. He’s also the co-director of the training core and chair of the publications committee of the Consortium of Eosinophilic Gastrointestinal Diseases Researchers (CEGIR). Since his arrival, he’s been impressed by the team at Children’s.

“The beauty of GI at Children’s of Alabama/the University of Alabama at Birmingham (UAB) is the fantastic people in the division,” he said. “People are our most valuable resource. Our people are here for the right reason, they have their heart in the right place, and they want to do the right thing.”

He wants to make their jobs easier and more efficient with stronger infrastructure and support systems, so, as he said, “We are working at the top of our license and being effective, rather than just busy.” That means ensuring goals and synergies are aligned. He also wants to drive the academic mission in addition to patient care. “We want to take care of all patients—from simple to complex—and serve the missions of Children’s and of UAB,” he said.

Gupta wants to make Children’s a destination of choice, not just of need, by patients. He envisions Children’s as a preeminent center of excellence, not only in Alabama, but also in surrounding areas regionally and nationally. His vision encompasses four As: access for patients, ambitions and aspirations for GI personnel and academic work.

Gupta’s special areas of focus are in eosinophilic GI diseases, nutrition, pediatric obesity and pediatric endoscopy. “What I love about this field is there is so much innovation happening, plus a strong national and international community,” he said. “Yes, we do procedures, but we also use our analytical skills because we are seeing patients in clinic and in the hospital and delivering exemplary care. GI provides an enviable mix of critical thinking and procedural skills.”


New Clinic Offers Care for Children with Pancreatitis

Children with chronic pancreatitis are at increased risk for multiple issues.

While pancreatitis is not as prevalent in children as in adults, it can be an aggressive disease resulting in significant morbidity and even death. Now, children with this condition have access to a multidisciplinary clinic at Children’s of Alabama designed to manage their medical, physical and emotional health needs.

Chinenye Dike, M.D. M.S, a pediatric gastroenterologist at Children’s, started the Pancreatic Disorders Center of Excellence clinic in January 2023. It serves children with any type of pancreatitis, whether it be a single episode or recurrent attacks and chronic pancreatitis. It also serves children with pancreatic ductal anomalies and exocrine pancreatic insufficiency from other causes such as Shwachman-Diamond syndrome. The clinic is the only National Pancreas Foundation Pediatric Center of Excellence in Alabama.

“A major advantage of the multidisciplinary format is the ability to address the diverse medical and psychosocial effects of chronic pancreatic diseases all in one place,” Dike said. “Children with chronic pancreatitis are at increased risk for multiple issues including constant pain, missed school, diabetes, poor nutrition and reduced quality of life.” By bringing together physicians, nutritionists, pain specialists, psychologists and other providers to evaluate and create integrated treatment plans for these patients, Dike says the clinic aims to improve long-term outcomes and reduce repeat hospitalizations.

The multidisciplinary team also includes a genetic counselor—because many children with chronic pancreatitis have genetic mutations—and a pediatric endocrinologist to address endocrine complications from chronic pancreatitis, such as Type 3c diabetes, which develops when the pancreas experiences damage, such as from chronic pancreatitis or cystic fibrosis.

The clinic sees patients once a month. “We have the potential to grow,” Dike said, “given the increasing need for specialized pediatric pancreatic care in Alabama and surrounding states.” Data shows that some children can develop chronic pancreatitis even without a first episode of acute pancreatitis, she says, while some children with a severe first episode of acute pancreatitis can progress to chronic pancreatitis within four years. Additionally, a child’s quality of life can be impaired, and complications can develop after just a single episode of acute pancreatitis.

Dike and her team also track outcomes, including patient-reported outcomes such as quality of life.


New Surgical Liver Transplant Director Hopes to Build on Transplant Center’s Success

Dr. Marcos Pozo Jatem joined Children’s of Alabama as the surgical liver transplant director in September 2022.

In March 2023, the Children’s of Alabama Transplant Center will celebrate its 10th anniversary. It’s a decade that’s been marked by growth, and leaders believe more is ahead.

One reason for that belief is the arrival of a new surgical liver transplant director. Marcos Pozo Jatem, M.D., arrived in September after completing a fellowship in pediatric transplant and hepato-pancreato-biliary (HPB) surgery at Lurie Children’s Hospital of Chicago. He’s also completed fellowships in abdominal transplant surgery and clinical bioethics at Northwestern and was a resident at Johns Hopkins. He’s a member of 10 professional societies related to surgery and transplant, holds nine board certifications and has won several surgery and teaching awards.

Pozo Jatem was drawn to the Children’s Transplant Center because of its history of success and potential for growth. The program currently serves three to five patients per year; he believes it can serve at least eight to ten. He hopes to build a referral pattern, especially for children in Alabama. A transplant hospitalization, he says, can last a couple months, depending on how complicated the transplant is. He doesn’t want a transplant family to have the additional burden of traveling outside the state to get the services they need.

“It is a significant investment for the family, not just economically, but also for rearranging other children that they may have, their school, the parents’ work commitments, and it’s sometimes very, very difficult for a parent, for a whole family to be uprooted like that to another state,” he said.

He also hopes to begin offering partial liver transplants, which are often ideal for smaller babies. For these patients, finding a donor match with a perfectly sized liver can be rare, even when the donor is similar in size to the recipient. Giving that child a portion of a larger liver can reduce the amount of time the child is on the transplant waiting list.

“Being on the waiting list and needing a liver is still a risky position to be in sometimes,” he said.

So far, Pozo Jatem has been impressed with the center’s culture. He says he’s humbled to join the transplant team, led by Jayme Locke, M.D., director of the Division of Transplantation; and Mike Chen, M.D., chief of the Division of Pediatric Surgery. The team also includes two hepatologists, Helena Gutierrez, M.D., and Henry Shiau, M.D., who have a partnership in patient care. “We share medical decisions; we constantly communicate and discuss evaluations, assessments and plans,” Gutierrez, the medical director of the liver transplant program, said. “We have a great partnership that has been built on open communication, respect and support.”

Pozo Jatem recognizes the team’s past efforts and the resulting growth and says he looks forward to helping the center grow more.

“I think the arc of progress has led us to this point that we can now expand on the services we can provide,” he said. “So that’s the thing that I’m most proud of—being part of a team that is interested in providing the best for children.”


Children’s Physicians Identify Adenovirus as Common Link in Hepatitis Outbreak

Adenovirus in the blood was a common link between cases during a recent hepatitis outbreak, according to researchers at Children’s of Alabama.

When a cluster of Alabama children were diagnosed with severe hepatitis in the fall of 2021, pediatric physicians at Children’s of Alabama and the University of Alabama at Birmingham (UAB) notified public health leaders and began investigating. As a result of their efforts, the Centers for Disease Control and Prevention (CDC) issued a health alert to warn the public about the spread of the illness. Hundreds more cases were subsequently discovered across the United States and Europe, many with a common link: adenovirus within the blood.

Researchers at Children’s and UAB discovered the link in the Alabama cases through a routine screening.

“We were able to uncover the possible association with the adenovirus-41 strain because it is our standard practice to screen patients diagnosed with hepatitis for adenovirus,” said Markus Buchfellner, M.D., a pediatric infectious disease physician at Children’s and UAB.

But the outbreak was something of a mystery to doctors. The nine patients in the Alabama cluster—all between 2 and 11 years old—were previously healthy. They lived in different parts of Alabama, and none attended the same day care or had known contact with any of the others. All developed severe hepatitis, with some experiencing acute liver failure and even requiring liver transplants.

“The adenovirus is typically associated with respiratory infections as well as gastrointestinal infections,” said Helena Gutierrez, M.D., Medical Director of the UAB and Children’s Pediatric Liver Transplant Program. “It is very rare for a healthy person to develop a severe illness that requires hospitalization from this virus.”

Gutierrez investigated the cases alongside Buchfellner and their colleague Henry Shiau, M.D., a pediatric hepatologist at Children’s and UAB. She served as lead author of the study, which was ultimately published in the New England Journal of Medicine. It showed that while the adenovirus was a common finding among the Alabama cases, it was unclear whether adenovirus infection itself, or a combination of the virus with other factors, led to the pediatric hepatitis outbreak.

Researchers noted that the timing of the outbreak during the COVID-19 pandemic should be considered, but it’s role also was unclear. COVID-19 is known to cause elevation of liver enzymes and multisystem inflammatory syndrome in children. The nine children tested negative for COVID-19 upon hospital admittance but did not receive antibody testing. While the outbreak remains a mystery, it’s clear that the work done by researchers at Children’s and UAB made an impact on the worldwide medical community. They led the way in researching the outbreak and alerting the public about symptoms and protective measures.