Discover and read the best of Twitter Threads about #LiverTwitter

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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
First, what is AI (adrenal insufficiency)?

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

➡️Random cort <10➡️AI!
➡️Random cort >9➡️ACTH stim

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:
3⃣What to do

#meded #medtwitter #MedStudentTwitter

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💩

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

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…

#livertwitter #GIJC #hpbcsm
- Sorafenib in 2008: improved OS + longer time to radiologic progression vs placebo…

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

Picture credit:…
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…

#livertwitter #GIJC #hpbcsm
✅ Sorafenib in 2008: improved OS + longer time to radiologic progression vs placebo…

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

[Picture credit:…]
Read 15 tweets
Practical TIPs for #TIPS in @AmCollegeGastro journal summarised here with #Tweetorial style


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

👍Good evidence: Recurrent hydrothorax, Budd-Chiari

❓evidence: HRS


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

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
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

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
3⃣only part of the HE story
Since I posted this tweetorial:

1. ISHEN released a consensus, touching on NH3.…. This features the fig below
2. A major publication on the variability and lability of Nh3 levels from @JasmohanBajaj @BloomPringle @AmCollegeGastro #amjgastro #livertwitter…
Read 4 tweets
What's the deal with ... Gilbert's syndrome?

Unconjugated bilirubin deserves its own #tweetorial

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

#livertwitter #meded #MedTwitter

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)



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)

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?

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?

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

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

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

#livertwitter #gitwitter #meded

First, why do variceal bleeds happen?

Throwback to this #tweetorial:


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

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!!

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

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
First, a poll:

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

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

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!…
Read 6 tweets
30-day Readmissions!

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

Join me for a #livertwitter #tweetorial?

1. What
2. Why
3. How to address

#QI #meded
Readmissions are:
1. Common. >1⃣in4⃣ pts readmitted by 30days (Fig1)…)
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

👎NSAIDs (mostly)
🤯Pharmacokinetics in ESLD

If this is a confusing topic for you, you are not alone!
Join me as we try 2 sort a few things out
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 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

1. What
2. Why
3. How to prevent/treat
4. ❤️ #cirrhosis physiology
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)
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!)
or see my review:… (Fig3)
Read 13 tweets
Hepatic encephalopathy in the hospital (An ode to #lactulose):
A brief #livertwitter #tweetorial
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

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?
Read 14 tweets
Why is your pt's ALT (or AST) >1000?
A #livertwitter #tweetorial

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?…
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

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