Discover and read the best of Twitter Threads about #LiverTwitter

Most recents (24)

HepatoADrenal syndrome

Say WHAT?!

⌚️It's #tweetorial o'clock

Be prepared to:
1⃣Define adrenal insufficiency of critical illness
2⃣never look @ a lipid panel the same
3⃣respect how sick ppl w/#cirrhosis get

#MedTwitter #meded #livertwitter
1/
First, what is AI (adrenal insufficiency)?

1⃣Critical illness can make the HPA axis😢
Fig1
⬇️Cortisol release
⬇️ACTH response
⬇️Tissue response to cort

2⃣Definition
Fig2-3
➡️Random cort <10➡️AI!
➡️Random cort >9➡️ACTH stim
➡️Cort⬆️<9➡️AI!

2/ ImageImageImage
Second: adrenal insufficiency(AI) is real, common & matters

1⃣Fig1:People who die from sepsis have:
⬆️baseline cort
⬇️ACTH response

2⃣Fig2:This time: correlation is causation
➡️norepi🚫work in AI
➡️give steroids, norepi work

3⃣Fig2: steroids (may) help for AI

3/ ImageImageImage
Read 9 tweets
Muscle cramps!

We have all had them
But imagine they woke you up every night
For many people with #cirrhosis, that's life!

A #livertwitter #tweetorial featuring:
1⃣Who
2⃣Why
3⃣What to do

#meded #medtwitter #MedStudentTwitter

1/7
Cramps in #cirrhosis

1⃣Mainly @🌙,in the🦵, intense
2⃣Common: 1 in 3 people
3⃣Risk factors? anyone cramps! No diff in labs!
4⃣Turns quality of life into💩

2/
But why cramps in #cirrhosis⁉️

1⃣⬇️ATP in muscle of ppl w/cirrhosis
🤔ATP needed for myosin to detach from actin

2⃣cramping in cirrhosis associated with
⬇️plasma volume &
⬆️renin activity
🤔Nerve perfusion depends on volume
&⬇️vol also⬆️sympathetic nerve activity

3/
Read 7 tweets
For #GIJournalClub – we will discussing the @NEJM article:
Atezolizumab + Bevacizumab in Unresectable HCC (IMbrave150 trial) by Dr. Richard Finn et al.
Expert opinion: @SeragHashem
Moderators: @AtoosaRabiee @jturnesv

nejm.org/doi/full/10.10…

#livertwitter #GIJC #hpbcsm
Background:
- Sorafenib in 2008: improved OS + longer time to radiologic progression vs placebo
nejm.org/doi/full/10.10…

Single agent PD-L1 inhibitor w/o improved OS
- Nivoumab vs sorafenib: No statistically significant improvement in OS w/nivolumab
sciencedirect.com/science/articl…
Background – drug mechanisms:
- Atezolizumab: a programmed death ligand 1 (PD-L1) inhibitor
- Bevacizumab: a monoclonal antibody targeting the VEGF
- Sorafenib: multikinase inhibitor

Picture credit: nature.com/articles/s4157…
Read 13 tweets
For #GIJournalClub – we will discussing the @NEJM article:
Atezolizumab + Bevacizumab in Unresectable HCC (IMbrave150 trial) by Dr. Richard Finn et al.
Expert opinion: @SeragHashem
Moderators: @AtoosaRabiee @jturnesv

nejm.org/doi/full/10.10…

#livertwitter #GIJC #hpbcsm
Background:
✅ Sorafenib in 2008: improved OS + longer time to radiologic progression vs placebo
nejm.org/doi/full/10.10…

Single agent PD-L1 inhibitor w/o improved OS
✅ Nivoumab vs sorafenib: No statistically significant improvement in OS w/nivolumab
sciencedirect.com/science/articl…
Background – drug mechanisms:
- Atezolizumab: a programmed death ligand 1 (PD-L1) inhibitor
- Bevacizumab: a monoclonal antibody targeting the VEGF
- Sorafenib: multikinase inhibitor

[Picture credit: nature.com/articles/s4157…]
Read 15 tweets
Practical TIPs for #TIPS in @AmCollegeGastro journal summarised here with #Tweetorial style

Indication:

💪Best evidence: Resistant ascites, 2nd prevention of EVB, rescue for EVB

👍Good evidence: Recurrent hydrothorax, Budd-Chiari

❓evidence: HRS

#livertwitter

(1/n)
Contraindication for #TIPS

🛑Absolute: severe HE, severe LF, HF/severe valve insuff, pul HTN, severe PPH, unrelieved bill construction, sepsis

⚠️Relative:⬆️age, hx of HE,⬆️MELD (>15-18),⬆️R/L heart pressure, PPH, extensive HCC/mets, severe coagulopathy/thrombocytopenia

(2/n)
Risk for #TIPS

⚡️Liver Failure: precipitating liver shock, ⬇️risk in patients w/ MELD <15-18

⚡️HE: 40% of pt, 1-2 wk or yrs after (⬆️diameter)
📌RF: diameter of TIPS, Hx of HE,⬆️age, sarcopenia, bad liver/renal function
📌Primary ppx is controversial

bit.ly/2BeF1Wl
Read 3 tweets
@AmCollegeGastro Virtual Grand Rounds meets #livertwitter - NASH - 🔑 Pts:
🩺 NAFLD Dx ➡️5% steatosis ; NASH has specific path criteria (🎈 dilatation, M-D bodies, etc); Exclude🍻 and other etiologies; Assoc w/ met. RFs
🌎 Prevalence 25%👨; 7-10%👧🧒 ; In DM II ➡️ 55.5%;
🍃 History - NAFLD➡️NASH➡️Cirrhosis➡️HCC. Non-linear progression also exists! HCC w/o cirrhosis (0.592%/year);
📈Predictors of Progress: (a) Met. RFs; (b) Stage of Fibrosis (>= F2)
⚕️ #2 indication for LT and ⬆️; #1 in ♀️
⬆️DALYs (07-17)
📊By 2030 ~800,000 excess liver deaths;
NAFLD assoc. w/ ⬆️🫀 events AND non-liver CA.! Also assoc. w/ FATIGUE ➡️👎 QOL
💱 Economic Burden -- $95.4 billion 💰lifetime cost of adv. NASH
NASH Diagnosis: 🪙 Standard = Liver Bx; But ⚠️; Can use Non-invasive Tests/Biomarkers e.g. U/S, TE, MRE, FLI, CK-18, FIB4, NFS, ELF etc
Read 8 tweets
Ammonia!

This test has such a big footprint in the landscape of liver disease management. But it is just too complicated to deserve its spotlight

Reposting this #tweetorial

NH3 levels:
1⃣a potent biomarker of illness
2⃣unreliable
3⃣only part of the HE story
#livertwitter
Since I posted this tweetorial:

1. ISHEN released a consensus, touching on NH3. pubmed.ncbi.nlm.nih.gov/32224704/?from…. This features the fig below
2. A major publication on the variability and lability of Nh3 levels from @JasmohanBajaj @BloomPringle @AmCollegeGastro #amjgastro #livertwitter

ncbi.nlm.nih.gov/pmc/articles/P…
Read 4 tweets
What's the deal with ... Gilbert's syndrome?

Unconjugated bilirubin deserves its own #tweetorial

Featuring:
🟨Why?
🟨Is it bad or...PLOT TWIST...good!?
🟨What to do about it?
🏆The most 🍌🍌trials ever conducted

#livertwitter #meded #MedTwitter

1/
What is Gilbert's?

1⃣Healthy person gets labs. Bili 2.4, >80% indirect
2⃣Student studies all🌙, forgets 2 eat.
In AM,👀slightly 🟨

Turns out:
👉3% of🌎has bili>1.4mg/dL (fig1)

Many things⬆️indirect bili:
👉Only 1⃣ makes bili⬆️w/fasting (Fig2)

It's...

2/
GILBERT'S SYNDROME

Who?1⃣Described c1901. Hilarious paper
(🙏google translate, my🇨🇦franglish education)
Why?2⃣Familial⬇️UDPGT protein
(the thing that 'conjugates' bili)
Why?3⃣Base pair insertion in UGT1A1 promoter
(#TATAbox, the gene that makes UDPGT)

3/
Read 11 tweets
What can patients with #NASH expect from clinical trials?

Recent negative results from $GILD and now $GNFT in Phase 3 highlight the uncertainties entering trials that patients face

Is there a minimum potential benefit a patient should accept when entering a trial?

THREAD
In Phase 3, participants with #NASH entering a trial there is no certainty that the drug being tested will work and they are taking a risk with a new treatment

Is there a minimum threshold for benefit in a trial that participants might expect?

2/n
Earlier today, I asked #livertwitter what the minimally important difference would be for histologic improvement in phase 3 trials in NASH

The majority thought that at least a 25% absolute improvement in either NASH or fibrosis was the minimum



3/n
Read 16 tweets
Have you ever wondered ... how beta-blockers treat #cirrhosis?

Here's a #tweetorial featuring:
1⃣Pathophys!
2⃣controversy!
3⃣Cheap, life-saving interventions!

#livertwitter #gitwitter #meded

1/
First, why do variceal bleeds happen?

Throwback to this #tweetorial:

tl;dr

1. #cirrhosis forces blood around the liver
2. Varices are bypass routes
3. Some run in the esophagus/gut
4. They can tear/bleed
5. Tragic

2/
Imagine this scene

It's 1980:
🩸variceal bleeds=surgical disease
🚫banding not invented
👶Sclero in its infancy
💉Somatostatin⬇️portal pressure,😢1/2-life
🩸🩸Rebleeding=the norm
⚰️Mortality crazy high

We need a durable way to ⬇️portal pressure!!

3/
Read 17 tweets
1/ Let's differentiate pyogenic from amebic liver abscess in a #Tweetorial today. We will examine DDx, risk factors, microbiology, clinical features, diagnostics, and treatment. This came from my most recent morning report. #IDTwitter #LiverTwitter #MedEd
2/ Differential diagnosis for liver abscess:
Infectious etiologies predominate. Most are pyogenic (bacterial). Amebic (Entamoeba histolytica) and hydatid cyst (Echinococcus) important. Differentiate these from HCC or liver mets. @CPSolvers what am I missing?!
3/ Pathogenesis of pyogenic liver abscess (PLA):
- Biliary obstruction (GB, cancer) most commonly
- Surgical complication, trauma
- Portal vein pyemia from intra-abdominal infection (e.g. appendicitis)
- Hematogenous seeding (endocarditis)
- Cancer tx complication (RFA, TACE)
Read 27 tweets
1/

Why is vibrio vulnificus so bad for people with liver disease?

🤯The answer could blow your mind!🤯

Join me for a #tweetorial:
Act 1: Epi of v. vulnificus: What’s the deal with oysters?!
Act 2: Mechanism

#cirrhosis #livertwitter #idtwitter
2/
First, a poll:

what is it about liver disease that makes vibrio vulnificus so bad for people with liver disease?
3/
Who is Vibrio vulnificus?

1⃣Halophile=Needs salt 2 live. i.e. lives in sea
2⃣Makes a 'chitinase', embeds in mollusks

Infections caused:
3⃣Open wound in sea water: cellulitis
4⃣Raw oysters: deadly bacteremia

Epi:
5⃣Fortunately Rare. 0.8 infections/100000ppl
Read 11 tweets
Welcome to my first #tweetorial! Inspired by @NnekaUfereMD's talk @AASLDtweets to give back as a trainee

There are many things to discuss with #cirrhosis patients.
Ascites, HE, varices, HCC, transplant, GOC, rehab: the list goes on.

#Nutrition needs to be part of that routine!
Why is this such a big deal?

Independent of severity of liver dysfxn, poor nutrition, sarcopenia leads to:
1⃣Lowers survival (HR 2.18)
2⃣Increased risk of infxn
3⃣Increased HE, ascites ➡️ lower QOL
4⃣Lower survival in post-transplant setting
But what’s so special about nutrition in #cirrhosis?

For that we have to do a VERY BRIEF return to med school and the 1953 Nobel Prize winning work on energy extraction (citric acid cycle) 3/
Read 9 tweets
What is #cirrhosis?

This is for patients & anyone who has ever asked:

❓ What is it
❓ Where did it come from?
❓Why do I feel this way?
❓ Am I dying?

A #livertwitter #tweetorial
First, what is the liver, anyway?

1⃣It's Huge (but hides under your ribs on the right side)
2⃣It's a filter (processes everything u eat or drink)
3⃣It's a factory (makes a ton of stuff u need to live)
4⃣It's a warehouse (stores a ton of stuff…that u need 2 live)
What is liver disease?

Basically, it's liver inflammation (🔥)

👉 2 main parts of the liver can be🔥(Pic 1)
👉 Lots can🔥the liver (Pic 2)

The problem:
🔥+ time = ⬆️chance of #cirrhosis
Read 13 tweets
Ceruloplasmin!

Are we trying to diagnosis Wilson Disease or ... do we just like to say ceruloplasmin?

Please join me for the last #tweetorial in a series on diagnostic tests for liver disease #livertwitter #meded
Interpret the following in the context of my COI:

Every time a ceruloplasmin is sent on a 70 year old, a part of my spleen infarcts.
Ceruloplasmin tests 4 Wilson Disease

What's that?
1⃣Prevalence 1/55,000. Avg age @ dx: 11
2⃣Mutated ATP7B gene⬇️Copper export from liver &⬇️cerulo formation
3⃣Copper gets everywhere (ie KF rings), damages liver &🧠
4⃣Diagnostic algorithm 4 liver disease of unknown cause
Read 8 tweets
What in the world is anti-smooth muscle antibody (SMA)!?

Join me for another quick-hit #livertwitter #tweetorial on this mysterious test used in the eval of autoimmune hepatitis

Second in a series on diagnostic testing for liver disease #meded
Autoimmune hepatitis is:
1⃣Rare, 2/100,000; higher with age.(Fig1)
2⃣Causes <1.8% of persistently elevated liver enzymes(Fig2)
3⃣Suggested by positive antibodies but best dx by biopsy. 👀diag criteria,Fig3
*nb: talking about Type1 AIH
Read 6 tweets
Elevated ferritin? Is it hemochromatosis? Probably not!

Join me for a quick-hit #livertwitter #tweetorial?

First in a series on diagnostic testing for liver disease #meded
Patients will tell us their diagnosis - if we are listening
In this @JAMAInternalMed teachable moment a patient with ⬆️AST/ALT & alcohol abuse was tested 4 hemochromatosis.

Ferritin = off the charts
Homozygous for HFE mutations
But did she have hemochromatosis?

See below!

jamanetwork.com/journals/jamai…
Read 6 tweets
30-day Readmissions!

They can teach us a lot about the management of #cirrhosis
AND
Highlight the systems of care that benefit patients with cirrhosis

Join me for a #livertwitter #tweetorial?

Aims:
1. What
2. Why
3. How to address

#QI #meded
Readmissions are:
1. Common. >1⃣in4⃣ pts readmitted by 30days (Fig1) cghjournal.org/article/S1542-…)
2. Costly. >$700 million/year
3. Morbid. Independently associated w/⬆️risk of death (Fig2)
4. Barely predictable. No matter what variables go in2 the model the AUROC ~0.6-0.7 (Fig3)
Q: Why do patients with #cirrhosis get readmitted so frequently?
Read 12 tweets
What's the deal with pain control in #cirrhosis?
A #meded #tweetorial with QI undertones

Aims:
👍Tylenol
👎NSAIDs (mostly)
🤯Pharmacokinetics in ESLD
🔪Tramadol

If this is a confusing topic for you, you are not alone!
Join me as we try 2 sort a few things out
#livertwitter
Let's start with a real world scenario:

Your patient has cirrhosis with well controlled ascites, HE, and unfortunately comes in with MSK back pain from raucously cheering in vain 4 the Winnipeg Jets.
They ask for advice/treatment. In addition to stretching/PT, you recommend...
Although APAP OD is☠️, @ lower doses it's safest analgesic
Speed limit=2-3g/d (I use 2g)
Wouldnt push it but take solace in:
Fig1: Tylenol tox=NAPQI>Glutathione (👀CYP2E1)
Fig2: Tho ppl assume cirrhosis⬇️glutathione, normal metabolism preserved
Fig3: 1 reason:cirrhosis⬇️CYP2E1
Read 13 tweets
How do we provide a prognosis of #cirrhosis?
A #livertwitter #tweetorial

Let's go deep to the very first prognostic tools
& see how everything old is new again.

Keywords: Child class, MELD, Frailty
First, a question:
What is the expected transplant-free survival for a person with a recent diagnosis of #cirrhosis?
Act 1: Necessity is the mother of invention

Imagine you are a patient w/a variceal bleed in 1940’s (Fig1)
No EGDs
No Banding/sclerotherapy
No hope!

And then came portosystemic shunt surgery(Fig2, I 👀U, A. Oldfather Whipple!)
Problem: Surgery⬇️rebleed but often⬇️survival (Fig3)
Read 14 tweets
Putting my #livertwitter #tweetorials in one place
I must have deleted my original index tweet.
(More are coming in 2019)
Read 5 tweets
What is hepatorenal syndrome?
A #Livertwitter #tweetorial

Hepatology is awesome, exciting, but also humbling.
Nowhere is that clearer than HRS, a true unmet need for patients with ascites

Aims
1. What
2. Why
3. How to prevent/treat
4. ❤️ #cirrhosis physiology
What:
1. Ascites trashes QOL & is deadly enough to merit mention in the bible(Fig1)
2. Ascites physiology damages other organs; Austin Flint said it 1st (Fig2)
3. HRS is the knockout punch of portal hypertension. What begins as elevated portal mmHg and ascites ends as HRS(Fig3)
What:
1. HRS is not rare in pts w/ascites (Fig1)
2. HRS is deadly (Fig2)
3. For a definition of terms, check out the Ascites Club (that's a thing!)
ref: gut.bmj.com/content/gutjnl…
or see my review: amjmed.com/article/S0002-… (Fig3)
Read 13 tweets
Hepatic encephalopathy in the hospital (An ode to #lactulose):
A brief #livertwitter #tweetorial
Aims:
1. Share the greatest t-shirt ever made
2. Rule out infection!
3. Laxation now! But how?

keywords: #cirrhosis, paracentesis, stool pH
1. This shirt, made by a patient, reminds us:
▶️HE is horrible, unpredictable
▶️Preventing HE is hard
▶️Dont be quick 2 label pts as 'noncompliant' - there's more to the story
▶️Our patients are awesome. Hepatology is the best

#lactuloseorcomatose
2. Think of hepatic encephalopathy as a biomarker.

For what? The answers form a mandatory checklist of sorts

1. Para to r/o SBP. Delay @ your patient's peril. (Fig1)
2. GI Bleeding?
3. UA/Blood Cultures/CXR
3. What's the Cr? Na? K?
review: nature.com/articles/s4139…
#AmJGastro
Read 14 tweets
Why is your pt's ALT (or AST) >1000?
A #livertwitter #tweetorial

Take-homes:
1. Top 3 causes of acute liver injury
2. I always say it's ischemic hepatitis; 50% of the time, I'm right every time

Brought to u by:
@tonybreu et al. What causes severe ALI?
cghjournal.org/article/S1542-…
The liver is awesome.

Yet its vocabulary is ... limited.

We can all tell when it is upset - high ALT, AST.

But that could mean anything!

So what's your specific patient's specific reason for high ALT?
First - a poll:
What's the most common cause of severe acute liver injury
(ALT or AST > 10xULN)?
Read 11 tweets

Related hashtags

Did Thread Reader help you today?

Support us! We are indie developers!


This site is made by just two indie developers on a laptop doing marketing, support and development! Read more about the story.

Become a Premium Member ($3.00/month or $30.00/year) and get exclusive features!

Become Premium

Too expensive? Make a small donation by buying us coffee ($5) or help with server cost ($10)

Donate via Paypal Become our Patreon

Thank you for your support!