GASTROINTESTINAL TIC BORNE INFECTIONS Martin D. Fried, MD, FAAP Pediatric Gastroenterology Physician Nutrition Specialist 3200 Sunset Ave Suite 100 Ocean, NJ 07712

Gastrointestinal Complaints abdominal pain abdominal painvomiting blood in stool constipation heartburn chest pain soilingdiarrhea mouth sores MULTISYSTEM difficult swallow Skin rashes

Apthous Ulcers

Canker Sore

Erythema Nodosum

Psoriasis

Ulcers

Colitis

Rectal Fissure

Skin Tag vs Granuloma

Psoriasis with Granuloma

Bartonella Borrelia burgdorferi H pylori Mycoplasma Salmonella, EBV Clostridium difficile

SINGLE INFECTIONS 30

COINFECTIONS = 20

TRIPLE INFECTIONS = 6

80 PATIENTS, 88 INFECTIONS

Heartburn, Abdominal Pain, Skin Rash, Gastritis, and Duodenitis Bartonella henselae

Cat Scratch FeverCat Scratch Fever LymphandenopathyLymphandenopathy hepatitis-elevated liver enzymes hepatitis-elevated liver enzymes SplenitisSplenitis PneumonitisPneumonitis Fever Unknown OriginFever Unknown Origin

Gastrointestinal Bartonella Hepatosplenic AbscessHepatosplenic Abscess Abdominal Pain-burningAbdominal Pain-burning Mesenteric Adenitis-mimic AppendixMesenteric Adenitis-mimic Appendix

GI Presentation HeartburnHeartburn Abdominal PainAbdominal Pain Skin Rash-striae –stretch marksSkin Rash-striae –stretch marks Enlarged Lymph nodesEnlarged Lymph nodes

VIOLACEOUS RASH

NEW BLOOD VESSELS

GI Infections tic bitetic bite No prior GI complaintsNo prior GI complaints No steroid useNo steroid use No abrupt weight gainNo abrupt weight gain

Infection and or Diet Pain not resolved by antacids, Histamine blockers, PPIPain not resolved by antacids, Histamine blockers, PPI

Skin Rash Violaceous- deep reddish purple Serpinginous- “snake like” Breast or lower back Groin or back knee Periumbilical (belly button) Inner thigh stretch marks are different stretch marks are different

Mesenteric Adenitis CT AbdomenCT Abdomen Lymph Nodes > 1cm in diameterLymph Nodes > 1cm in diameter May mimic appendicitisMay mimic appendicitis

Endoscopy and Biopsy AssesstheGI mucosaAssesstheGI mucosa –H. pylori –Bartonella by PCR –Borellia burgdorferi PCR –Mycoplasma PCR –Ehrlichia and Babesia PCR

Bartonella Pathology Chronic Gastritis and or duodenitisChronic Gastritis and or duodenitis No UlcerNo Ulcer No evidence of allergy (eos)No evidence of allergy (eos) No Acute Inflammation (polys)No Acute Inflammation (polys)

Bartonella Rashes MaculopapularMaculopapular UrticarialUrticarial Erythema Nodosum (crohns also)Erythema Nodosum (crohns also) Granuloma Annulaire (ringworm)Granuloma Annulaire (ringworm) Thrombocytopenic PurpuraThrombocytopenic Purpura Leukoclastic VasculitisLeukoclastic Vasculitis

Striae Endothelial ProliferationEndothelial Proliferation Differentiate from stretch marksDifferentiate from stretch marks in obese or steroid using patientsin obese or steroid using patients

Bartonella GI Inflammation An Association ShownAn Association Shown IL-2, IL-6, IL-10, ElicitedIL-2, IL-6, IL-10, Elicited

Interleuken 6 Multipotent cytokineMultipotent cytokine Elicited by InfectionsElicited by Infections Induces inflammationInduces inflammation

NEOVASCULARIZATION NEW BLOOD VESSELS

STEROID EFFECT

SERPINGINOUS RASH = INFECTION

SNAKE LIKE = INFECTION

Helicobacter pylori Bacteria Infects humans only Transmitted - human to human

H. pylori Irritant to stomach liningIrritant to stomach lining Cause of gastric, duodenal ulcersCause of gastric, duodenal ulcers Lifelong infection unless treatedLifelong infection unless treated Predispose to stomach cancerPredispose to stomach cancer due to chronic irritation due to chronic irritation

Helicobacter pylori NodularityGastritis NodularityGastritis

Eradication of H. pylori Two antibiotics for two weeks ClarithromycinAmoxacillin Proton pump inhibitor for a month intracellular death of infection

Mycoplasma Intracellular infectionIntracellular infection Rarely in the bloodRarely in the blood Worsens Lyme, Bartonella symptoms Worsens Lyme, Bartonella symptoms Fibromyalgia, CFS, RA, and Gulf WarFibromyalgia, CFS, RA, and Gulf War

Mycoplasma protein Stimulates immune cells Stimulates immune cells Proinflammatory cytokines Proinflammatory cytokines TNFalpha, IL-1, IL-6 TNFalpha, IL-1, IL-6 GI may resemble Crohn’s GI may resemble Crohn’s

Chronicity of Mycoplasma Surface antigenic variation Surface antigenic variation Supress host immune responses Supress host immune responses Slow growth rates Slow growth rates Intracellular locations Intracellular locations Can take 3 years to eradicate Can take 3 years to eradicate Can follow IgM and IgG titers Can follow IgM and IgG titers

Celiac vs Food Intolerance Celiac is Autoimmune to wheat, rye, barley Celiac is Autoimmune to wheat, rye, barley Gluten, Genetics and Environment Gluten, Genetics and Environment Intolerance is IgE or non IgE mediated Intolerance is IgE or non IgE mediated

Inflammation causes permeable gut Foreign proteins to immune system Crohn’s, Colitis, Celiac

Treatment complications

Candida Albicans

Normal Flora Yeast Normal Flora Yeast Antibiotics kills Normal Flora Antibiotics kills Normal Flora Yeast overgrowth occurs Yeast overgrowth occurs Diet to produce lactobacillus, bifidobacteria Diet to produce lactobacillus, bifidobacteria Short chained fructooligosaccharides (FOS) Short chained fructooligosaccharides (FOS) Not a casein or gluten related problem Not a casein or gluten related problem

Clostridium difficile C. difficile is normal bacterial flora C. difficile is normal bacterial flora Antibiotics kill lactobacilli, bifidobacter Antibiotics kill lactobacilli, bifidobacter C. difficile overgrowth occurs C. difficile overgrowth occurs C. difficile elicits – Toxin A and Toxin B C. difficile elicits – Toxin A and Toxin B Pseudomembranous colits Pseudomembranous colits Treat with Metronidazole and probiotics Treat with Metronidazole and probiotics However, prebiotics help L and B multiply However, prebiotics help L and B multiply

Pseudomembranous Colitis

Foods with sc FOS Banana onions Banana onions garlic asparagus garlic asparagus Barley wheat Barley wheat Tomatoes leeks Tomatoes leeks

Conclusions Lyme, Bartonella, Mycoplasma occur in the GI tract of children 5-21 yrs Lyme, Bartonella, Mycoplasma occur in the GI tract of children 5-21 yrs PCR biopsies to document infection PCR biopsies to document infection Consider Coinfections Consider Coinfections Prevent yeast, c. difficile overgrowth with prebiotics and probiotics Prevent yeast, c. difficile overgrowth with prebiotics and probiotics