Discover and read the best of Twitter Threads about #cirrhosis

Most recents (10)

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
The history of the Child-Turcotte-Pugh score has a mystery

Yesterday, I sent out a #meded #tweetorial on #cirrhosis prognosis that began with the story of how the Child Class

But did you know that Child was the SECOND to describe the class system?
Child and Turcotte published their score in a texbook chapter in 1963.(Fig1)
Who reads texbooks?
But Wantz and Payne published their score 1st, in 1961, in the the @nejm(Fig2)
It is basically no different than Child's score(Fig3)
And the outcomes predicted were the same(Fig4)
Apparently, Wantz/Payne were old colleagues of Child, and while I could find a nice biography of Wantz (link.springer.com/content/pdf/10…), I could not find anything about Dr. Mary Ann Payne. If anyone knows more about this pioneer in liver surgery, please let me know
Read 4 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
portopulmonary hypertension (PPH) and how I found hepatology:
a #cirrhosis #tweetorial
I had no clue what I was going to do in med school

And 1st year...it sucked. Soul-crushing memorization
Didnt feel like the kind of meaningful learning I experienced in college
Then I had the opportunity to shadow a bad-ass transplant anesthesiologist.
She changed my life
I was introduced to a pt w/#cirrhosis & PPH.
She was diagnosed after being screened (see criteria Fig1)
PPH was controlled (see tx options Fig 2)
But she had a rocky time periOp.
Desperate, my mentor started imatinib based on a recent case report (Fig3)
She did better!(Fig 4)
Read 10 tweets
Hepatopulmonary Syndrome - or is Portopulmonary hypertension? What’s the diff (brief #tweetorial)
Pulm complications of #cirrhosis can be devastating. This month on rounds, I was reminded that these conditions are confusing.
#meded
Step 1:
Recognize when a pulmonary complication could be present or clinically important (4 transplant)
This is how they looked when first described:
1. Portopulmonary: Dyspnea without hypoxia (Fig 1)
2. HPS: Hypoxia (Fig 2)

Step 2:
TTE (Fig 3)
Ordering "agitated saline" echocardiography will always be funny

TTE▶️most sensitive way 2 dx HPS(Fig1)
The bubbles dont go right▶️left immediately (like with septal defects) but do after a few heart beats
Bonus: do not rely on pulse ox!(Fig2)
Screen or go 2 TTE on by symptoms
Read 8 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
Introducing the “The Hepatologist’s CBC”

A #cirrhosis #tweetorial all about the platelet

Aims:
- Identify cirrhosis based on blood tests-
- Understand why platelets are low in #cirrhosis
- Describe the plt’s role in the #cirrhotic #coagulopathy

#livertwitter
The hepatologist's dream:
identify patients with cirrhosis before complications like HCC and variceal bleeding.

Enter the platelet count
Shout out to JAMA's Rational Clin Exam Series & Udell et al's big beautiful systematic review ncbi.nlm.nih.gov/pubmed/22357834
Platelets are low in #cirrhosis.
We can use this to our advantage - even sparing biopsies.

Easy to do. E.g. Google: FIB-4
(ref aasldpubs.onlinelibrary.wiley.com/doi/abs/10.100…)

There are many platelet-based scores to help ID cirrhosis.
(review: ncbi.nlm.nih.gov/pubmed/2883446
Read 14 tweets
What's the deal with Ammonia in hepatic encephalopathy?
A #cirrhosis QI #tweetorial

Aims
Try to answer this question while also showing
1) Ammonia levels dont matter
2) U should not restrict protein in patients with HE

Keywords: "ammonia hypothesis", sarcopenia
First, a poll:
Does Ammonia cause hepatic encephalopathy?
How did NH3 get involved with #HE in the first place?

Step 1: In 1877 Eck develops the first successful vascular anastamosis, a portocaval shunt. ncbi.nlm.nih.gov/pubmed/9186464
Step2: Pavlov improves it
Step3: Dogs get goofy after eating meat:"Meat stupor"
Step4: What's up with meat!?
Read 26 tweets
A celebration of paracentesis: a QI #Tweetorial

For all my twitter friends who care for inpatients with #cirrhosis

Take home messages: paras for all, FFP for none
Keywords: #SBP and the #cirrhotic #coagulopathy
First - which hospitalized patient needs a diagnostic para?

Patients with ascites and:
Spontaneous bacterial peritonitis (SBP) is a deadly condition. Appropriate tx can prevent hepatorenal syndrome and death.

How many patients are asymptomatic?

Many.

In this study from Pinzello et al, 1 in 3 patients with SBP were "silent"
aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.10…
Read 19 tweets

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