This paper in #amjgastro compared refeeding @ 24 v48 hrs after endoscopic interventions for peptic ulcers. 24 hours was “not noninferior”. multiple limits
1️⃣ ⬆️mortality in 48h
2️⃣diff duration of iv ppi
My 🌶🌶 take: feed your patients when they want!
This @LiverInt multinational study shows that noninvasive tests help sort high from low risk for liver-related events and, to a degree, ❤️events in #nafld
🌶take: this is how we need to do #nafld epi from now on
🛑the madness!
Biofire PCR tests 4 stool “infections” are positive in 14% of healthy controls (!!!) & offer limited to no prognostic information in ppl with #ibd
🌶🌶🌶take: These tests are out of control, riddled with false positives. Check cdiff &manage clinically. @ibddoctor
PEARL ALERT:
Memory is preserved in Minimal hepatic encephalopathy
WHY I LIKED THIS @AGA_CGH PAPER
1️⃣mainly before HCC treatment. 🌶: shouldn’t be used before egd
WHAT COULD BE BETTER
1️⃣weird bleeding defn. No diff periop!
2️⃣🌶I wish the comparison was no plts!
PMID:32205226
“Have I told u FIB-4 rocks?” Vol 47
👉200000 people without known liver disease followed for 1.7million person-years in korean health exam database
👉high fib-4 = ⬆️⬆️mortality
Pmid: 32090451
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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
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
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
We found that broad testing didn’t add much costs but increased false positives, especially when pretest probability of NAFLD was high
Then, In this RCT, John Dillon comparing usual care to broad evaluation of elevated liver enzymes, the cost per incremental diagnosis was 284💷 but was def cost-effective
This is a powerful method. But poorly understood, often maligned. My goal is to improve critical appraisal and help good analyses get the appreciation they deserve
All CEA begins with a clinical decision where we are uncertain about the best path forward. Nevertheless, when we face patients we must do something, even if that something is nothing. CEA brings our dilemma to life. Helping us quantify trade offs
Usually we compare a fair description of usual care to an alternative - make sure you agree the choice is fair, realistic, and represents an actual clinical dilemma
There's lots of tests you can order.
But most diagnoses are made in the H+P
Like this one
In fact, in this case, my attending said the diagnosis was obvious from the beginning
Just not to me
When I meet someone with ALT>1000, I think:
1⃣Ischemic hepatitis. Right 🫀failure? 🫀-genic shock? Cool legs?
2⃣Biliary 🪨. Pain? imaging!
3⃣Drug induced liver injury. Tylenol? Run every med through livertox.gov
4⃣Viral hep. Hep A/B/C
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.
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