The correct answer is variceal bleeding
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.
Why is that?
next slide please
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.
Why is that?
next slide please
https://twitter.com/ebtapper/status/1622263807128092674
Ammonia is a biomarker of badness
1. Liver dysfunction
2. Portosystemic shunting
3. Dehydration, renal injury (🫘eliminates nh3)
4. Sarcopenia (💪eliminates nh3)
5. Malnutrition
6. And upper GI bleeding
1. Liver dysfunction
2. Portosystemic shunting
3. Dehydration, renal injury (🫘eliminates nh3)
4. Sarcopenia (💪eliminates nh3)
5. Malnutrition
6. And upper GI bleeding
Where is all that ammonia coming from?
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
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
https://twitter.com/ebtapper/status/1622217106438717441?s=20&t=ovdaBXPI_NtP8Hsg_-7Jng
He may be at risk for withdrawal and even have some alcohol ketoacidosis but that would not be what I am MOST worried about.
That being said, acidosis CAN increase the ammonia (review: kidney-international.org/article/S0085-…)
That being said, acidosis CAN increase the ammonia (review: kidney-international.org/article/S0085-…)
I ❤️that so many people wanted to rule out infection. Every hospitalized patient with #cirrhosis is high risk for infection. This patient has a higher WBC and lactate. Bring on that diagnostic para!
But he doesnt have an infection
Next slide
But he doesnt have an infection
Next slide
With an NH3 that high but no signs of overt encephalopathy, it is highly unlikely that he is infected
That's because of this formula I made up
Encephalopathy = NH3 x Inflammation
That's because of this formula I made up
Encephalopathy = NH3 x Inflammation
So IF he had an infection he would be more likely to have hepatic encephalopathy.
And he doesn't have HE
He is alert and oriented.
He may have early or covert HE - subtle symptoms and deficits in executive function. This condition worries me. But MOST worried?
And he doesn't have HE
He is alert and oriented.
He may have early or covert HE - subtle symptoms and deficits in executive function. This condition worries me. But MOST worried?
Inflammation:
1. For many, it may be necessary for HE:
2. When HE happens at low Nh3, it is often in people with infections (Figure below pubmed.ncbi.nlm.nih.gov/31658104/)
3. Can identify people with early HE pubmed.ncbi.nlm.nih.gov/35032100/
1. For many, it may be necessary for HE:
https://twitter.com/ebtapper/status/1292417638493126656?s=20&t=ovdaBXPI_NtP8Hsg_-7Jng
https://twitter.com/ebtapper/status/1018666750597005312?s=20&t=ovdaBXPI_NtP8Hsg_-7Jng
2. When HE happens at low Nh3, it is often in people with infections (Figure below pubmed.ncbi.nlm.nih.gov/31658104/)
3. Can identify people with early HE pubmed.ncbi.nlm.nih.gov/35032100/
In sum:
A mentally intact man with #cirrhosis comes in with severely elevated ammonia, high lactate, evidence of consumed hemostatic factors, decreased hemoglobin, and tachycardia. I am most worried about variceal bleeding in this case
A mentally intact man with #cirrhosis comes in with severely elevated ammonia, high lactate, evidence of consumed hemostatic factors, decreased hemoglobin, and tachycardia. I am most worried about variceal bleeding in this case
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