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

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

3. Apthous Ulcers

4. Canker Sore

5. Erythema Nodosum

6. Psoriasis

7. Ulcers

8. Colitis

9. Rectal Fissure

10. Skin Tag vs Granuloma

11. Psoriasis with Granuloma

14. Bartonella Borrelia burgdorferi H pylori Mycoplasma Salmonella, EBV Clostridium difficile

15. SINGLE INFECTIONS 30

16. COINFECTIONS = 20

17. TRIPLE INFECTIONS = 6

18. 80 PATIENTS, 88 INFECTIONS

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

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

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

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

23. VIOLACEOUS RASH

24. NEW BLOOD VESSELS

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

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

28. 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

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

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

33. 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)

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

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

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

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

40. NEOVASCULARIZATION NEW BLOOD VESSELS

42. STEROID EFFECT

44. SERPINGINOUS RASH = INFECTION

45. SNAKE LIKE = INFECTION

46. Helicobacter pylori Bacteria Infects humans only Transmitted - human to human

47. 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

50. Helicobacter pylori NodularityGastritis NodularityGastritis

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

52. 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

53. 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

54. 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

55. 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

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

58. Treatment complications

59. Candida Albicans

60. 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

61. 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

62. Pseudomembranous Colitis

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

66. 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