Here's a #tweetorial featuring:
1⃣Pathophys!
2⃣controversy!
3⃣Cheap, life-saving interventions!
#livertwitter #gitwitter #meded
1/
Throwback to this #tweetorial:
tl;dr
1. #cirrhosis forces blood around the liver
2. Varices are bypass routes
3. Some run in the esophagus/gut
4. They can tear/bleed
5. Tragic
2/
![](https://pbs.twimg.com/media/EXU4GtxUYAAVMJC.jpg)
It's 1980:
🩸variceal bleeds=surgical disease
🚫banding not invented
👶Sclero in its infancy
💉Somatostatin⬇️portal pressure,😢1/2-life
🩸🩸Rebleeding=the norm
⚰️Mortality crazy high
We need a durable way to ⬇️portal pressure!!
3/
So how do beta-blockers work?
7/
1⃣Impeded outflow⬆️intrahepatic resistance(Fig1)
2⃣More gut delivery thru splanchnic vasodilation
3⃣🔃variable cardiac❤️output(fig2)
(most are hyperdynamic...but some are not!)
9/
![](https://pbs.twimg.com/media/EXVFExuU0AEqOGu.png)
![](https://pbs.twimg.com/media/EXVFUywU0AA0rm0.png)
Carvedilol can do it!(fig1)
1⃣Beta>alpha. #cirrhosis metabolism is steroselective, s-enantiomer is B>A(Fig2)
2⃣⬆️Half-life & bioavailability in cirrhosis(Fig3)
3⃣RCT:May be more effective than propranolol(Fig4)
12/
![](https://pbs.twimg.com/media/EXVGaLeVcAAc6bm.png)
![](https://pbs.twimg.com/media/EXVGcntUEAELCS3.png)
![](https://pbs.twimg.com/media/EXVGfwzU4AIq4IX.jpg)
![](https://pbs.twimg.com/media/EXVGkgBUMAIsji2.png)
Beta-blockers were the hottest topic of #livertwitter 2010-2015!
Let me tell you what happened
13/
2010:⬆️mortality in bad ascites(fig1)
2012:'window theory'(fig2)
(some need xtra❤️output)
2014:⬆️HRS&mortality after SBP(Fig3)
BB strikes back
🔥apology 4BB journal-of-hepatology.eu/article/S0168-…
2015: BB⬆️Waitlist survival!(f4)
2016: Mic drop meta-analysis(f4)
14/
![](https://pbs.twimg.com/media/EXVG3LHU8AEFQxA.jpg)
![](https://pbs.twimg.com/media/EXVG6LuU4Ag_MuF.jpg)
![](https://pbs.twimg.com/media/EXVG8_fUwAIpvyP.jpg)
![](https://pbs.twimg.com/media/EXVHUO8VcAA-jce.jpg)
1⃣BB⬇️flow 2gut but also⬇️cardiac output
2⃣BB ⬇️mortality
3⃣BB metabolism is different in cirrhosis. Carvedilol even @ 12.5mg qHS is adequate
4⃣BB safe but caution w/low BP,sick❤️
FIN
1️⃣which BB you using in Saudi Arabia @drmoutaz ? Boston @tony_breu?
2️⃣how u handling periop @aoglasser?
3️⃣which in kids @Dr_NOvchinsky ?
4️⃣ever start in icu? @AvrahamCooperMD