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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
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

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