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
Does Ammonia cause hepatic encephalopathy?
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!?
![](https://pbs.twimg.com/media/DiKe1C_X0AA3tTF.jpg)
![](https://pbs.twimg.com/media/DiKfxXsX0AEDPp7.jpg)
ncbi.nlm.nih.gov/pmc/articles/P…
McDermott was awesome:
War hero, fixed Muhammad Ali's hernia, revolutionized liver surgery
Here is his obit: nytimes.com/2001/07/25/us/…
In the OR:
A 5cm pancreatic cancer with superior mesenteric vein involvement.
To resect in 1 stage, he smacked the portal vein onto the inferior vena cava- Eck fistula!
He pub'd this story in 1952:
ncbi.nlm.nih.gov/pmc/articles/P…
![](https://pbs.twimg.com/media/DiKYaAzWsAA5Btm.jpg)
Everyone was stumped
So they studied him to figure it out.
It took 6 months
#NoIRB
Lots of bad things
Let me send you to a few references:
ncbi.nlm.nih.gov/pubmed/10728803 @JHepatology
ncbi.nlm.nih.gov/pubmed/12668989 @HEP_Journal
![](https://pbs.twimg.com/media/DiL2wsxX4AESqwz.jpg)
There, I said it
But is it the whole story?
Turns out, Ammonia levels have nothing to do with grade of HE
We knew this in 1963!
annals.org/aim/article-ab…
![](https://pbs.twimg.com/media/DiKh67bXcAAZY8z.jpg)
![](https://pbs.twimg.com/media/DiKjRb3XUAAL_9L.jpg)
ncbi.nlm.nih.gov/pubmed/12637132
Low levels usually good but even 1 in 13 people with Grade 4 HE (coma) have stone-cold normal NH3.
And an ammonia level of 150 could mean anything from no HE to coma.
![](https://pbs.twimg.com/media/DiKjXIXWAAA-4UB.jpg)
![](https://pbs.twimg.com/media/DiKjmGBX0AIHB1E.jpg)
NH3 levels just cannot diagnose or grade HE.
But why?
This causes inflammation
Inflammation enhances diffusion of NH3 into the brain
(review: aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.10…)
Don't forget: lots of HE is PRECIPITATED by what, u guessed it, infections (inflammation!)
![](https://pbs.twimg.com/media/DiLxNeWWAAA7F81.jpg)
This led to 🔽 cog function
Now, Abx 🔽 inflammation
Sp they gave Abx which 🔽 inflammation
Then they🔼 NH3 ...but there was no cognitive dysfunction!
journal-of-hepatology.eu/article/S0168-…
![](https://pbs.twimg.com/media/DiKrakOWsAcV4pc.jpg)
![](https://pbs.twimg.com/media/DiKrd3qWAAc295T.jpg)
We have no way of accounting for the impact (and amount) of inflammation.
Ammonia is bad and I certainly dont want to cause meat stupor!
Should I ask my patient with cirrhosis to eat a low protein diet?
If your liver is not working
and the portal HTN is shunting blood
We need a second line of defense
We have one:
It's the muscle!
NH3 may rise after a protein-rich meal ... but it is safe
RCT: ncbi.nlm.nih.gov/pubmed/15246205
RCT: ncbi.nlm.nih.gov/pubmed/18627001
Guideline: ncbi.nlm.nih.gov/pubmed/16707194
If you are interested in more stuff about ammonia, here's a plug for our paper "Refining the Ammonia Hypothesis" in @MayoProceedings sciencedirect.com/science/articl… with @Vilas_Pat and @ZGordonJiang