Thread by @WesElyMD

1/🧵🎥 MAJOR TIPS about #Liver Disease
 
Why do we ask pts to “hold up traffic”? When people get severe liver disease, “asterixis” is a finding on exam we often see.

What does it mean?
 
#MedTwitter #NurseTwitter #TipsforNewDocs #Addiction

2/ Asterixis indicates that toxins like ammonia have built up in the body because the scarred liver no longer filters them out. The brain cells no long function normally (#Delirium or Hepatic #Encephalopathy) & can no longer control muscle movements like posture!

3/ These same toxin cause vessels to dilate and develop problems with blood flow in the skin and lungs. A skin finding is called “spiders.” They look like a multi-legged spider, right? It’s a tip-off.

4/ The Papal Sign is another weird thing in liver disease. Patient’s hands may develop an involuntary scarring that leads the 4th and 5th finger to bend down like the Pope giving a blessing.

5/ The abdomen gets full of ascitic fluid that we drain with a needle. Look how protuberant this belly is and a picture of what the drained fluid can look like. What does it mean? Well we have to study it with lab data.

6/ We look for infection called “SBP” – spontaneous bacterial peritonitis. Most doctors don’t know the origin of the 250 WBC neutrophils as the best cut-off. #CLASSIC paper: bit.ly/3yLnGNh
 
#TipsforNewInterns

7/ The other #CLASSIC thing we need to know is the Runyon Criteria showing the best cut-off for thicker fluid indicating infection or cancer is a “SAAG” < 1.1 (Serum Ascites Albumin Gradient) vs. >1.1 meaning portal hypertension: bit.ly/2VxPYg4

8/ Patients often suffer from #DeliriumTremens or DTs. It can be from alcohol withdrawal. Most people use benzos, but they aren’t evidence based. A new study recommended phenobarbital, but really we need to do a proper randomized trial!
 
bit.ly/3yLVkT7

9/fin
Last tip: Resist benzodiazepines for DTs. There are better ways than “converting” everyone to quiet delirium. For DTs, I use dex & clonidine (alpha-2 agonists) - an extrapolation based on Dahlia Study data: bit.ly/3yDIwhI