Discover and read the best of Twitter Threads about #cirrhosis

Most recents (24)

WHAT is the deal with Milk Thistle?
WHY is it used to treat liver disease?
HOW does it work?
DOES it work?
ARE you ready for a #tweetorial?
#medtwitter #livertwitter Image
Milk Thistle, a history:
1⃣Use to treat snake bites (Dioscorides)
2⃣To carry off bile (Pliny the Elder)
3⃣Great for liver disease (1500's: Otto Brunfels)
4⃣In 19th Century 🇺🇸, the 'Eclectics' popularized herbology, especially milk thistle, for the liver ImageImageImageImage
Fast forward to today:
1⃣Herbal supplements are a multibillion dollarindustry
2⃣A quarter of the population takes an herbal supplement
3⃣~5% of the US population is using Milk Thistle, including 12% of people with liver disease

What do they get out of it? ImageImage
Read 12 tweets
⭐️New-pub alert!!
@APASLnews guidelines on management of #ascites in liver disease.
Salient features covered which are different from other guidelines👇🏻
✅Diagnostic approach to mixed ascites
✅Role of low-dose albumin (1/n)… Image
✅Recommendations on use of ACE inhibitors/ARBs
✅Diagnostic approach to management of pleural effusion
✅Recommend ICA definition for defining renal dysfunction in refractory ascites
✅Start with low-dose diuretics and gradually increase dose to increase tolerability (2/n)
⭐️Diagnostic algorithm for workup of new onset #ascites 👇🏻

✅SAAG - diagnosis of portal hypertension
✅High SAAG, high protein ascites - use BNP, 2D echo, SPA doppler and thyroid profile
✅Low SAAG, high protein ascites - use ascitic fluid ADA, amylase and TG (3/n) Image
Read 10 tweets
The correct answer is variceal bleeding

First, the lactate is up. Take this patient seriously
Second, the obvious clues are lower hemoglobin, platelet consumption.
Third, the ammonia is crazy high. This seals the deal for variceal bleeding.

Why is that?

next slide please
Ammonia is a biomarker of badness

1. Liver dysfunction
2. Portosystemic shunting
3. Dehydration, renal injury (🫘eliminates nh3)
4. Sarcopenia (💪eliminates nh3)
5. Malnutrition

6. And upper GI bleeding
Where is all that ammonia coming from?

The answer is hemoglobin and albumin are isoleucine-poor. This means that when our blood enters the gut, it is not a nutritious source of protein. It gets broken down for waste. That waste, my friends, is ammonia
Read 9 tweets
On a mission to make physical examination in the ICU great again in 2023: do you worry when the knees of your ICU patient look like the image below? #PCCM #MedEd…
Knee mottling should get ur attention, here is why: mottling score (0=no mottling, 1=coin size, 2=superior edge of the knee cap, 3=middle thigh, 4=groin fold and 5=anything higher than the groin fold) at 6 h was predictive of 14 day ICU mortality #MedEd…
Mottling score was predictive of mortality regardless of vasopressor dose needed. It was also associated with lactate levels and low urinary output. #MedEd
Read 5 tweets
1/ 🚨 #5Pearls on Alcohol-Associated Hepatitis 🚨

Why is it an immune response?

✔️Direct EtOH insult ➡️ inflammation

✔️Disruption of the gut barrier ➡️ bacteria & inflammatory cells go up portal vein ➡️ to hepatocytes

Sponsor: @Pan_Financial Image
2/ Now, What else may be going on & what imaging and labs would you send off for ddx for Alc Hep?

Listen to the episode to hear a powerful story from @etapper differentiating Alc hep and worsening #cirrhosis Image
3/ What interventions are most linked to improved mortality?

Alcohol cessation and nutrition!

Alcohol leads to⬇️absorption of proteins, carbs, and fats as well as impaired absorption of micronutrients = Alc Hep induces catabolic state

See some tips below for daily targets! Image
Read 4 tweets
The best way to ensure best outcomes for your patient with variceal bleeding is to treat it

Sadly: 1 in 7 bleeds receives no endoscopic therapy

Why? 🧵

The top reasons I have seen are:

🚫But the varices weren’t bleeding at the time
✅varices bleeding can be intermittent. #cirrhosis plus hemetemesis and varices at EGD = band

🚫I couldn’t visualize with all the 🩸
✅take time, reposition patient, use eryrhromycin
🚫not comfortable banding
✅phone a friend or transfer quickly

🚫cannot pass bander given patient anatomy
✅time for sclerotherapy (or glue)
Read 5 tweets
🔥Highlight from @BavenoVII #cirrhosis session

CSPH Cut-off:
✅Rule in: LSM>25kPa
✅Rule out: LSM<12kPa, Plt>150


#ILC2022 #Livertwitter @ReibergerThomas @RodriguesSu24 @crisripol @jaumebosch9 @EASLnews Image
Defining Recompensation @BavenoVII

✅Regression (struc/func)
⛔️Primary etiology
⛔️Decompensation (<12m)
✅Stable Liver func

#ILC2022 #LiverTwitter @ReibergerThomas @RodriguesSu24 @crisripol @MattiasMandorf1 @jaumebosch9 @ggarciatsao Image
🔥PSVD by Dr Aurelie Plessier @ValdigGroup

Based on #clinical/#histo
✅Specific signs
✅Non-specific signs
🗝️Histology essential for diagnosis (nor now)
👉emerging role: NOT in PSVD

#ILC2022 #LiverTwitter @BavenoVII @ggarciatsao @ReibergerThomas @VirginiaHdezGea @jaumebosch9 ImageImageImage
Read 3 tweets
🔥#ACLF-3: early vs late transplant @JosephAlukal

👉UNOS database: n=3,498
✅Better 90-day and 1-year survival for early LTx (<7 days)
🤔 Selection bias who goes for early vs late LTx?

#ILC2022 #Livertwitter @EASLedu @EASLnews
@VinaySundaramMD @RajivJalan1 @DrLiver @ebtapper
🔥Urine NGAL predicts response to Terlipressin/albumin in HRS by Dr Carmine Gambino

N=162 #cirrhosis, 🇮🇹
urine NGAL:
⬇️ in Terli responders
💡NGAL>220 predict 90-day Mortality (AUROC: 0.85)

#ILC2022 #Livertwitter @salvatore_piano @ProfPaoloAngeli
Read 7 tweets
🌎Global CLEARED registry by @JasmohanBajaj

n=1,383; Reason for admission: GI bleeding🩸, HE🧠
✅Infection🦠: 25%
✅AKI: 46%
✅30-D Readmission: 33%
🪦30-D Mortality: 33%
😟Transplant: 11%

#ILC2022 #LiverTwitter @EASLedu
Recruitment/selection policy on post-LTx in ACLF-3 by Dr Thierry 🇫🇷

🪦3-year survival: ACLF-3 ⬇️ 66% vs 82%
✅Volume ⏫, survival ⏫
✅Survival gap diminished btw #ACLF-3 vs non-AC LF 3👍


💡MDT, post-ICU care, TAM score, surgery/anes
✅ICU network (list from ICU)
⛔️When not to transplant #ACLF-3?

Combination of:
💡Age, Lactate, MDR infection, Respiratory


#ILC2022 #Livertwitter
Read 5 tweets
📢Personalized medicine in #NAFLD by @DrLoomba

✅Current gaps in #NAFLD:
- Rapid progressors
- non-cirrhotic HCC

😧At risk NASH (F2 beyond)? Try these👇
✅FAST (low PPV) - exclude biopsy
✅MAST (PPV 91-97) - rule-in & treat

#ILC2022 #Livertwitter @EASLedu
Personalized medicine in #NAFLD by @DrLoomba

🔥Gut microbiome (AUROC 0.936)
- Detect advanced #fibrosis
- Identify 1st-degree relative with #cirrhosis (ethnically universal)
👉DOI: 10.1016/j.cmet.2020.06.005

- FGF19 treatment response in #NASH

#ILC2022 #LiverTwitter @EASLedu
Personalized #NASH treatment by @DrLoomba

Choose yr drugs based on🎯
#Fibrosis reversal vs #NASH resolution?

✅Combination = way forward. Why?
⏬Dose ( ?potentially ⏬AE)

#ILC2022 #LiverTwitter @jturnesv @aelsharkawy75 @IanARowe @DharJahnvi @drshafikuchay
Read 4 tweets
A patient with #cirrhosis and hepatic hydrothorax was admitted to an ICU 3 times for severe shortness of breath and hypoxia for urgent thoracentesis and diuretics

So we put in an indwelling catheter

Within weeks the output was minimal

What happened?

This patient had ascites (weekly paras), hydrothorax, & high MELD including INR of 1.9, and plt 32.

She was small, weak. Sarcopenic.

Her creatinine 1.3.
Did you know that creatinine over-estimates renal function in women with #cirrhosis?

See MELD-Grail:… @AsraniSumeet
Read 11 tweets
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

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