Discover and read the best of Twitter Threads about #cirrhosis

Most recents (24)

Tomorrow is the last meeting of the @AASLDtweets Practice Metrics Committee (PMC) chaired by @AsraniSumeet

He is the kindest, most committed collaborator and has done so much to shape and support the future of #cirrhosis quality

#livertwitter @serperm
Sumeet was chair of this committee after Michael Volk and @KanwalFasiha. Under their leadership, we:

1. Defined the key PROs in #cirrhosis:
2. Developed quality metrics for #cirrhosis that included the patient voice:
3. Developed quality metrics for liver cancer diagnosis and management:

Soon you will hear from the committee on PROs in liver cancer, metrics for liver transplant, and metrics for the management of #cirrhosis coagulopathy
Read 4 tweets
The hepatitis B vaccine is amazing.

It also has a wild backstory
Want to hear it?

A #tweetorial


#livertwitter #MedTwitter Image

Hepatitis B sucks
1⃣About 3-4 in every 100 people have it
2⃣It causes liver cancer, #cirrhosis

But the vaccine rocks!
1⃣Prevents liver cancer!
2⃣Was first recombinant vaccine!

So let's get into it

2/ ImageImageImage
Did you know that the discovery of hepatitis B was recognized with the 1976 @NobelPrize for Dr. Baruch Blumberg?

His studies over the course of 5 years 1964-1969 changed the world.

Let's take a look

3/ Image
Read 19 tweets
I don’t get the vitamin k thing. There is no known benefit ( And the harm is that It sends mixed signals. It undoes the teaching about the #cirrhosis coagulopathy. Because iv vit k is special and novel, it’s a consult rec that sticks. Needs reconsidering
For my #livertwitter friends replying about vit K deficiency in malnutrition, I am not mad at ya, I have nothing but love for you! I see - and address - malnutrition in every patient I meet! I am pro-food, pro-vitamin! I am happy we can still talk this out
Read 4 tweets

WHY are steroids used for alcoholic hepatitis?
WHAT is the deal with prednisolone vs prednisone?
WHERE did the discriminant function come from?
ARE you ready for a #tweetorial

#livertwitter #medtwitter #meded #cirrhosis

Alcoholic hepatitis is a life-threatening acute liver injury featuring a liver full of necrotic cells, "Mallory bodies" of cellular junk, & severe inflammation (neutrophils)

Fig1: Mallory's original description
Fig2: Alc hep Mortality in 1966 according to bilirubin

Where did we get the idea for steroids in alc hep?

Everyone in 1950's France was using steroids to treat #cirrhosis. As in the examples below, Prednisone/prednisolone were said to resolve ascites, edema, jaundice, and fevers. They made patients hungry and happy too
Read 17 tweets
How many times must a patient with hepatic encephalopathy poop?

Turns out...we don’t know

In this genius study by @doctornikkid, there was no diff in cognitive function between those with 2-3 💩or less… #livertwitter #cirrhosis
What this tells me:

1️⃣lets not torture our patients with more Lactulose if they don’t need
2️⃣cog function *as we measure it* does not matter but QOL, functioning/PROs, risk of overt HE do - let’s study them
3️⃣develop stool/blood/PRO biomarkers of Lactulose response
And.... I forgot to tag @JasmohanBajaj, senior author, who consistently fosters revolutions in how we think about and manage hepatic encephalopathy
Read 3 tweets

WHY is there a BABOON in my room?

A #tweetorial about the outcomes of hepatic coma, how far we have come, and how wild things got along the way

Up first: the lingo

Hepatic encephalopathy (HE) presents as a spectrum with subtle cognitive/motor deficits at one end (AKA "Covert HE") and coma at the other

HE/Coma can be caused by #cirrhosis (Type C, more common) and acute liver failure (Type A)

What used to (1950s/60s) happen to patients with coma due to hepatic encephalopathy ("HE coma")?

1⃣Gabuzda said everyone died
2⃣Sherlock said it was 68% mortality, Stormont 63%
3⃣Prytz said it was 80% mortality at 6-months
Read 22 tweets

HOW long do you live with #cirrhosis?
WHERE did MELD Score come from?
WHAT is a "TIPS"?
ARE you ready for re-#tweetorial

#livertwitter #medtwitter #meded

Imagine you are a patient with variceal bleed in 1940


Then came portosystemic shunt surgery. A treatment!

The catch?

Lots of people still died after surgery

What do we want to know so we can select the patients who will benefit from shunt surgery?

🤔Liver function?
🤔Do they look & feel well?
🎉Why not both!?

Wantz & Payne developed an A-B-C score using
5⃣Muscle wasting
Read 14 tweets

WHY does #cirrhosis cause palmar erythema?
HOW is estrogen involved?
WHO is ready for a #tweetorial?

Let's talk hormones, the liver, the impact of imbalanced testosterone/estrogen, & the history of spironolactone
#livertwitter #medtwitter #MedEd

Palmar erythema is:
1⃣Common (3 in 4 with #cirrhosis)
2⃣variably distributed on palm surface
3⃣caused by dilated capillaries

In 1942, Perrera showed the dilated vessels were not present on autopsy. A circulating factor must cause it.

What could it be?

Enter William Bean.
He knew that:
1⃣Palmar erythema happens in🤰
2⃣A 1940 paper showed that estrogen causes capillary dilation (in🐇🐇)

So, of course, he...
injected estrogen into men w/#cirrhosis & controls without.
Those w/#cirrhosis developed palmar erythema.
Read 16 tweets
Hi Kiran, Im sorry 4 ur loss. Ur statements R real, not bluff. Thank U 4 sharing ur father's (RIP) report of liver #cancer.

1/ Nw, coming back to ur original statement.
Modern #medicine said dad wil hav 8 mo to survive, but #homeopathy gave him 4 yrs.

2/ Im stil convinced #homeopathy did not work

And I knw Y U felt tat way

I blame UR oncologist - he mayB gud wit diagnosis, but he has no insight & communication skils

I blame ur #homeopath.
He is a quack but gud with communication skills

Want to knw why? Let me xplain👇
Be4 we start, chek this figure from @nature
This shows latest guidelines on treatment of #liver cancer, survival and options.
Luk at stage 0 and stage A [stable #cirrhosis, early disease)
Survival > 10 yr - transplant
Survival > 6 yr - removal surgery, tumor burn (ablation)
Read 11 tweets
Most fun study I have ever done:

We asked clinicians why they tested NH3, their pre-test prob of HE, and what they planned to do while they were blinded to the result

tl/dr: Clinicians are good at diagnosing HE in the ED, so no need for Nh3…
We find that a clinicians' pre-test probability of HE is the same as the post-test probability. But! not only does Nh3 add nothing diagnostically, when high it leads to excess lactulose use even when tested in people without #cirrhosis

Now we need to design the QI intervention
I have always wanted to do this study. Huge thanks to @juanjgonMD 4 doing it. Even if u dont care about Nh3, we are very proud of our design, which allowed us to assess the value of a test using the clinician's real-time reasons for testing and prior probability
Read 4 tweets

WHERE does ascites come from?
HOW do diuretics treat ascites?
ARE you ready for a #tweetorial?

#livertwitter #medtwitter #MedEd
First, ascites is:
1⃣Fluid in the belly
3⃣A cruel trick the liver plays on the heart and kidney

Throw back to my "what is #cirrhosis?" tweetorial

The first 'lesion' in ascites formation is the fibrotic liver.

Fibrotic liver:
⬆️sinusoidal hydrostatic pressure
⬆️lymph formation

"Mo sinusoidal pressure, mo lymph"
- Ernest H. Starling MD, personal communication
Read 15 tweets
#Ayurveda treatment for alcoholic #liver #cirrhosis - case based protocol, described in a case series of 3 patients.
Once again, forget @NetflixIndia comedy shows, this is where all the fun, comedy and jokes are now.

Caution: This limited series will drop your IQs
🔅#Ayurveda is a philosophy. Correct. No therapeutic value.
🔅Uncertainty due to uncertainty😳 HUH?
🔅#Ayush guys got 'sanskrit' spelling wrong 😵 whats with that?
🔅Time to combine evidence based medicine with case based medicine. What #herb is the author on?
🌿Alcoholic is not correct. Alcohol related/associated. More compassion toward patient. But what does #Ayurveda know abt compassion right? Need a herb 4 that.
🌿Specifically note the sentence bad mouthing scientific, conventional care. That's hw these #ayush #quacks survive.
Read 6 tweets
Read thread 👇 for key points about the Scarred Liver Project which demonstrates #EvidencetoImpact as we lead up to #WorldEBHCDay on 20 Oct.
Impact story by Neil Guha Tile with portrait shot of ...
Deaths from #LiverDisease in the UK continue to rise. In the majority of patients, liver disease is preventable and caused by lifestyle-related risk factors such as excessive alcohol use, type 2 #diabetes and #obesity.
In the UK, 50% of patients are first diagnosed with liver disease following an emergency admission to hospital with complications from liver failure. These patients have a reduced quality of life, a short life expectancy and expensive associated healthcare costs.
Read 11 tweets
Sharing our invited review: Transjugular intrahepatic portosystemic shunt (TIPS) in #cirrhosis/World #Journal of #Gastroenterology. @SRajesh_IR helms 24-page colossus discussing exhaustively recent studies #livertwitter #MedTwitter #irad #GITwitter
Full: Image
Topics we discuss include - variceal bleeding (incl ectopic), #ascites & #hydrothorax (incl chylous), #complications, new techniques, #stent size dilemma & extensive point of care algorithmic approaches in portal hypertension complications, eg: esophageal #variceal bleeding 👇 Image
#New techniques such as combined approach for difficult anatomy situation in TIPS in cirrhosis 👇 Image
Read 7 tweets
Our invited expert review on #Ayurvedic #herbals and #liver #toxicity. #herbal #medicine is NOT safe. Review on #herbs used in #Indian #traditional #medicine & adverse events is lacking in #published #Literature
We deep searched, compiled
Full paper:
1/4 Image
This #review is important for #ayush practitioners and those interested in opting for #alternative #therapies as #knowledge regarding potential #toxic components is the #right of every #patient and #moral #duty of the physician. This 👇 list show names of imp toxic herbs.
2/4 Image
We give #real #life #patient data supporting our review: such as this example which shows that #Ayurveda #drugs cause severe #chronic #liver #damage that can lead to #cirrhosis in the short term.
The implicated agent here is Holarrhena antidysenterica (Tellichery bark)
3/4 Image
Read 5 tweets
#livertwitter #irad #MedEd #MedTwitter
Large tortuous paraumbilical vein shunt in #patient with #Cirrhosis and #portalhypertension. @SRajesh_IR 👌
1/3 Image
Post coil (CARTO) and glue, complete disappearance of shunt ✌️
#phtsig #radiology #MedStudentTwitter
2/3 Image
#Tipss #procedure performed along with shunt occlusion, for recurrent #ascites 3/3
Complete resolution of portal hypertension complications 💯🎯 Image
Read 3 tweets
HOW does gabapentin work?
DOES gabapentin work?
WHY is gabapentin so shady?

Join me for a #tweetorial?

Keywords: Glutatmate, Asterixis, Alcohol-use disorder
#livertwitter #MedTwitter #meded

Admitting a non-#cirrhosis patient with gabapentin overdose as an intern, I saw asterixis

This 🤯

If it caused asterixis (throwback: ), did that mean it causes HE?

Gabapentin has confused me ever since
Everything about gabapentin is🍌
What follows is no different

There once was a💡dream💡 of using GABA signaling 2 prevent seizures. Yada yada yada, we made GABApentin. It approved in 1993!

Just one prob:
GABApentin doesnt bind GABA-receptors!

Like I said…🍌
Read 13 tweets
#livertwitter #GITwitter #MedTwitter #tweetorial
#Cirrhosis, right lobe atrophied, relative hypertrophy of left lobe
📌Splenic/superior mesenteric vein blood flow changes👉distortion of liver structure, re-routing hepatotropic substances to left, less to right➡️ Rt atrophy
1/ Image
❓But in #BuddChiari #Syndrome, caudate lobe enlarged
📌"#laminar flow’ theory"👉 larger redistribution of nutritients,hormones,hepatotropic factors to left hemi-liver at caudate level, most portal branches supplying caudate lobe from left portal vein #MedStudentTwitter
2/ Image
#Fatigue primary biliary cholangitis (#PBC)
📌cholestasis, #endotoxemia, systemic #Inflammation👉dysautonomia, central/peripheral neurovascular dysfunction, sympathetic overactivity, impaired baroreflexes, low peripheral #muscle perfusion, lactic acid mishandling, fatigue
Read 9 tweets
1mo writing, 4mo #PeerReview
Finally! Our invited #publication on #infections in #cirrhosis World Journal of #Hepatology
Update on diagnosis and management of sepsis in cirrhosis
Full paper:
Exhaustive discussions, new stuff..1/4
#livertwitter #MedTwitter Image
...a lot of important defining and prognosis powered scoring systems used in #sepsis 2/4
#MedStudentTwitter Image
...biomarkers new and old for sepsis 3/4
#ScienceTwitter #medicine #biomarkers Image
Read 4 tweets
Hepatic encephalopathy (HE)

⬇️Quality of life

We want to intervene early!
Predicting it is tough
No blood biomarker
Cognitive testing is <good, rarely done
There has to be a better way!

Check out:
#livertwitter #cirrhosis Image
We followed ~300 people with Child A/B #cirrhosis without prior HE.

Many developed overt HE

We derived a risk score - MASQ-HE - that outperfomed many others for prediction.

A - Activity impairment(0-10)
S - ChairStands/30 seconds
Q - QOL (SF-8)
#livertwitter ImageImage
Take home messages:

We used symptoms to predict overt episodes.
And you can too!

Listen to the patient
Ask about activity impairment
check chair-stands

These signs have prognostic power and could influence the decision to start treatment
Read 3 tweets
What is asterixis?

👋Described~60 yrs ago by Adams/Foley
👋Methods:60pts w/impending hepatic coma vs controls
👋Flapping flexion/extension, best @ the🤚but happens even 2 the 👁️lids! Has intervening tremor (mini-asterixis)

Look 4 it while checking handgrip!
Why asterixis?

2⃣Ammonia? Unlikely!(fig1)
3⃣Precipitating factors? Asterixis, like HE itself, is a biomarker of badness: bleeding, infection, sedatives(Fig2)
4⃣They looked @🧠; swollen astrocytes! Particularly in the basal ganglia!(Fig3)
#livertwitter 2/4
Why asterixis part 2

A study using magnetoencephalography showed:
1⃣There is 'excessive corticomuscular motor coherence' 2⃣Diseased basal ganglia fail to select and pace the motor areas

This seems to confirm what Adams/Foley found in the brain

Read 5 tweets
#Advice - #DONT drink #AloeVera or eat its #extracts
📌Very #liver #toxic, especially #cirrhosis
📌Possibly cause #Cancer
📌Damage #cell #DNA
See: &
👇patient #liverbiopsy - lightpink area all liver cells #DEAD
1/2 Image
📌Check your #nutrition #supplements
📌Double check #famous #weightloss supplements
📌Aloe-Vera = #Herbal liver injury
📌Some benefit in #skincare #dermatology, nothingelse!
📌Always disclose to your #Doctor
#MedTwitter #MedStudentTwitter #Ayurveda
Nobody follows this. Whole #plant is mostly used! #plantbased supplemental diets with whole Aloe-Vera for treating conditions like #diabetes and #jaundice leads to #catastrophe
#regulation = 0 in #India. All Aloe Vera treatments by #WhatsApp #Doctors Image
Read 5 tweets

1. Affects your liver
2. Extremely infectious
3. Many show no symptoms
4. Vaccine protects you
5. Can be treated
6. You can live a long, productive life with #HepatitisB infection if you treated.

A thread 🧵

{RT for awareness!} Image
First, #HepatitisB, like other viral hepatitis, loves the #liver.

Once infected, the virus goes straight to your liver, multiplies alarmingly, & tries to evade immune attacks.
In some, immune system clears the virus so they recover. In others, no, so they remain infected. Image
People who remain infected with #hepatitisB over a long period of time may develop liver issues.
Such liver problems may include #fibrosis, #cirrhosis, #livercancer, & #liverfailure.
If not detected & treated on time, the person may die of these complications. Image
Read 17 tweets
Strange cause for #cirrhosis
Maybe very #rare #MedEd
53yrs man, voice change, recurrent headaches, male breast enlargement. Stops socialising. Has bleed one day, #endoscopy varices, #biopsy fatty liver cirrhosis
No metabolic syndrome.
MRI Brain done. #livertwitter #radio
1/3 Image
What is the diagnosis?
In patients with cirrhosis, always try to find the cause in those who present early. There is no idiopathic, no cryptogenic. Its all 'missed' cirrhosis.
2/3 #liverpath
#MedTwitter #pathology #radiology #MRI #brain #Neurology #Endocrinology #NeuroTwitter Image
#diagnosis: #fatty liver related cirrhosis due to #pituatory macro adenoma with high prolactin, high GH, low #thyroid function. #clinical examination, acromegaly features with central obesity. #Examine 1st, then investigate. #MedicalStudent #medicine #MedStudentTwitter
Read 4 tweets

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