Elliot Tapper Profile picture
Hepatologist @michiganliver @vaannarbor; #cirrhosis; encephalopathy; frailty; quality improvement; father; husband. #livertwitter
Anil Gopinath Profile picture Pedro Ochoa-Allemant Profile picture salah salahi Profile picture Tom Numrych Profile picture medicalmoe Profile picture 12 added to My Authors
12 Aug
What is asterixis?

👋Described~60 yrs ago by Adams/Foley
👋Methods:60pts w/impending hepatic coma vs controls
👋Flapping flexion/extension, best @ the🤚but happens even 2 the 👁️lids! Has intervening tremor (mini-asterixis)

Look 4 it while checking handgrip!
#livertwitter
1/4
Why asterixis?

1⃣Adams/Foley:🤷
2⃣Ammonia? Unlikely!(fig1)
3⃣Precipitating factors? Asterixis, like HE itself, is a biomarker of badness: bleeding, infection, sedatives(Fig2)
4⃣They looked @🧠; swollen astrocytes! Particularly in the basal ganglia!(Fig3)
#livertwitter 2/4
Why asterixis part 2

A study using magnetoencephalography showed:
1⃣There is 'excessive corticomuscular motor coherence' 2⃣Diseased basal ganglia fail to select and pace the motor areas

This seems to confirm what Adams/Foley found in the brain

3/4
Read 5 tweets
1 Jul
HepatoADrenal syndrome

Say WHAT?!

⌚️It's #tweetorial o'clock

Be prepared to:
1⃣Define adrenal insufficiency of critical illness
2⃣never look @ a lipid panel the same
3⃣respect how sick ppl w/#cirrhosis get

#MedTwitter #meded #livertwitter
1/
First, what is AI (adrenal insufficiency)?

1⃣Critical illness can make the HPA axis😢
Fig1
⬇️Cortisol release
⬇️ACTH response
⬇️Tissue response to cort

2⃣Definition
Fig2-3
➡️Random cort <10➡️AI!
➡️Random cort >9➡️ACTH stim
➡️Cort⬆️<9➡️AI!

2/
Second: adrenal insufficiency(AI) is real, common & matters

1⃣Fig1:People who die from sepsis have:
⬆️baseline cort
⬇️ACTH response

2⃣Fig2:This time: correlation is causation
➡️norepi🚫work in AI
➡️give steroids, norepi work

3⃣Fig2: steroids (may) help for AI

3/
Read 9 tweets
28 Jun
Muscle cramps!

We have all had them
But imagine they woke you up every night
For many people with #cirrhosis, that's life!

A #livertwitter #tweetorial featuring:
1⃣Who
2⃣Why
3⃣What to do

#meded #medtwitter #MedStudentTwitter

1/7
Cramps in #cirrhosis

1⃣Mainly @🌙,in the🦵, intense
2⃣Common: 1 in 3 people
3⃣Risk factors? anyone cramps! No diff in labs!
4⃣Turns quality of life into💩

2/
But why cramps in #cirrhosis⁉️

1⃣⬇️ATP in muscle of ppl w/cirrhosis
🤔ATP needed for myosin to detach from actin

2⃣cramping in cirrhosis associated with
⬇️plasma volume &
⬆️renin activity
🤔Nerve perfusion depends on volume
&⬇️vol also⬆️sympathetic nerve activity

3/
Read 7 tweets
22 May
Ammonia!

This test has such a big footprint in the landscape of liver disease management. But it is just too complicated to deserve its spotlight

Reposting this #tweetorial

NH3 levels:
1⃣a potent biomarker of illness
2⃣unreliable
3⃣only part of the HE story
#livertwitter
Since I posted this tweetorial:

1. ISHEN released a consensus, touching on NH3. pubmed.ncbi.nlm.nih.gov/32224704/?from…. This features the fig below
2. A major publication on the variability and lability of Nh3 levels from @JasmohanBajaj @BloomPringle @AmCollegeGastro #amjgastro #livertwitter

ncbi.nlm.nih.gov/pmc/articles/P…
Read 4 tweets
20 May
What's the deal with ... Gilbert's syndrome?

Unconjugated bilirubin deserves its own #tweetorial

Featuring:
🟨Why?
🟨Is it bad or...PLOT TWIST...good!?
🟨What to do about it?
🏆The most 🍌🍌trials ever conducted

#livertwitter #meded #MedTwitter

1/
What is Gilbert's?

1⃣Healthy person gets labs. Bili 2.4, >80% indirect
2⃣Student studies all🌙, forgets 2 eat.
In AM,👀slightly 🟨

Turns out:
👉3% of🌎has bili>1.4mg/dL (fig1)

Many things⬆️indirect bili:
👉Only 1⃣ makes bili⬆️w/fasting (Fig2)

It's...

2/
GILBERT'S SYNDROME

Who?1⃣Described c1901. Hilarious paper
(🙏google translate, my🇨🇦franglish education)
Why?2⃣Familial⬇️UDPGT protein
(the thing that 'conjugates' bili)
Why?3⃣Base pair insertion in UGT1A1 promoter
(#TATAbox, the gene that makes UDPGT)

3/
Read 11 tweets
6 May
Have you ever wondered ... how beta-blockers treat #cirrhosis?

Here's a #tweetorial featuring:
1⃣Pathophys!
2⃣controversy!
3⃣Cheap, life-saving interventions!

#livertwitter #gitwitter #meded

1/
First, why do variceal bleeds happen?

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/
Imagine this scene

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/
Read 17 tweets
13 Jan
1/

Why is vibrio vulnificus so bad for people with liver disease?

🤯The answer could blow your mind!🤯

Join me for a #tweetorial:
Act 1: Epi of v. vulnificus: What’s the deal with oysters?!
Act 2: Mechanism

#cirrhosis #livertwitter #idtwitter
2/
First, a poll:

what is it about liver disease that makes vibrio vulnificus so bad for people with liver disease?
3/
Who is Vibrio vulnificus?

1⃣Halophile=Needs salt 2 live. i.e. lives in sea
2⃣Makes a 'chitinase', embeds in mollusks

Infections caused:
3⃣Open wound in sea water: cellulitis
4⃣Raw oysters: deadly bacteremia

Epi:
5⃣Fortunately Rare. 0.8 infections/100000ppl
Read 11 tweets
19 Oct 19
What is #cirrhosis?

This is for patients & anyone who has ever asked:

❓ What is it
❓ Where did it come from?
❓Why do I feel this way?
❓ Am I dying?

A #livertwitter #tweetorial
First, what is the liver, anyway?

1⃣It's Huge (but hides under your ribs on the right side)
2⃣It's a filter (processes everything u eat or drink)
3⃣It's a factory (makes a ton of stuff u need to live)
4⃣It's a warehouse (stores a ton of stuff…that u need 2 live)
What is liver disease?

Basically, it's liver inflammation (🔥)

👉 2 main parts of the liver can be🔥(Pic 1)
👉 Lots can🔥the liver (Pic 2)

The problem:
🔥+ time = ⬆️chance of #cirrhosis
Read 13 tweets
15 Jul 19
Ceruloplasmin!

Are we trying to diagnosis Wilson Disease or ... do we just like to say ceruloplasmin?

Please join me for the last #tweetorial in a series on diagnostic tests for liver disease #livertwitter #meded
Interpret the following in the context of my COI:

Every time a ceruloplasmin is sent on a 70 year old, a part of my spleen infarcts.
Ceruloplasmin tests 4 Wilson Disease

What's that?
1⃣Prevalence 1/55,000. Avg age @ dx: 11
2⃣Mutated ATP7B gene⬇️Copper export from liver &⬇️cerulo formation
3⃣Copper gets everywhere (ie KF rings), damages liver &🧠
4⃣Diagnostic algorithm 4 liver disease of unknown cause
Read 8 tweets
6 Jul 19
What in the world is anti-smooth muscle antibody (SMA)!?

Join me for another quick-hit #livertwitter #tweetorial on this mysterious test used in the eval of autoimmune hepatitis

Second in a series on diagnostic testing for liver disease #meded
Autoimmune hepatitis is:
1⃣Rare, 2/100,000; higher with age.(Fig1)
2⃣Causes <1.8% of persistently elevated liver enzymes(Fig2)
3⃣Suggested by positive antibodies but best dx by biopsy. 👀diag criteria,Fig3
*nb: talking about Type1 AIH
Read 6 tweets
3 Jul 19
Elevated ferritin? Is it hemochromatosis? Probably not!

Join me for a quick-hit #livertwitter #tweetorial?

First in a series on diagnostic testing for liver disease #meded
Patients will tell us their diagnosis - if we are listening
In this @JAMAInternalMed teachable moment a patient with ⬆️AST/ALT & alcohol abuse was tested 4 hemochromatosis.

Ferritin = off the charts
Homozygous for HFE mutations
But did she have hemochromatosis?

See below!

jamanetwork.com/journals/jamai…
Read 6 tweets
21 Jun 19
30-day Readmissions!

They can teach us a lot about the management of #cirrhosis
AND
Highlight the systems of care that benefit patients with cirrhosis

Join me for a #livertwitter #tweetorial?

Aims:
1. What
2. Why
3. How to address

#QI #meded
Readmissions are:
1. Common. >1⃣in4⃣ pts readmitted by 30days (Fig1) cghjournal.org/article/S1542-…)
2. Costly. >$700 million/year
3. Morbid. Independently associated w/⬆️risk of death (Fig2)
4. Barely predictable. No matter what variables go in2 the model the AUROC ~0.6-0.7 (Fig3)
Q: Why do patients with #cirrhosis get readmitted so frequently?
Read 12 tweets
23 Apr 19
What's the deal with pain control in #cirrhosis?
A #meded #tweetorial with QI undertones

Aims:
👍Tylenol
👎NSAIDs (mostly)
🤯Pharmacokinetics in ESLD
🔪Tramadol

If this is a confusing topic for you, you are not alone!
Join me as we try 2 sort a few things out
#livertwitter
Let's start with a real world scenario:

Your patient has cirrhosis with well controlled ascites, HE, and unfortunately comes in with MSK back pain from raucously cheering in vain 4 the Winnipeg Jets.
They ask for advice/treatment. In addition to stretching/PT, you recommend...
Although APAP OD is☠️, @ lower doses it's safest analgesic
Speed limit=2-3g/d (I use 2g)
Wouldnt push it but take solace in:
Fig1: Tylenol tox=NAPQI>Glutathione (👀CYP2E1)
Fig2: Tho ppl assume cirrhosis⬇️glutathione, normal metabolism preserved
Fig3: 1 reason:cirrhosis⬇️CYP2E1
Read 13 tweets
19 Feb 19
The history of the Child-Turcotte-Pugh score has a mystery

Yesterday, I sent out a #meded #tweetorial on #cirrhosis prognosis that began with the story of how the Child Class

But did you know that Child was the SECOND to describe the class system?
Child and Turcotte published their score in a texbook chapter in 1963.(Fig1)
Who reads texbooks?
But Wantz and Payne published their score 1st, in 1961, in the the @nejm(Fig2)
It is basically no different than Child's score(Fig3)
And the outcomes predicted were the same(Fig4)
Apparently, Wantz/Payne were old colleagues of Child, and while I could find a nice biography of Wantz (link.springer.com/content/pdf/10…), I could not find anything about Dr. Mary Ann Payne. If anyone knows more about this pioneer in liver surgery, please let me know
Read 4 tweets
19 Feb 19
How do we provide a prognosis of #cirrhosis?
A #livertwitter #tweetorial

Let's go deep to the very first prognostic tools
& see how everything old is new again.

Keywords: Child class, MELD, Frailty
First, a question:
What is the expected transplant-free survival for a person with a recent diagnosis of #cirrhosis?
Act 1: Necessity is the mother of invention

Imagine you are a patient w/a variceal bleed in 1940’s (Fig1)
No EGDs
No Banding/sclerotherapy
No hope!

And then came portosystemic shunt surgery(Fig2, I 👀U, A. Oldfather Whipple!)
Problem: Surgery⬇️rebleed but often⬇️survival (Fig3)
Read 14 tweets
23 Jan 19
portopulmonary hypertension (PPH) and how I found hepatology:
a #cirrhosis #tweetorial
I had no clue what I was going to do in med school

And 1st year...it sucked. Soul-crushing memorization
Didnt feel like the kind of meaningful learning I experienced in college
Then I had the opportunity to shadow a bad-ass transplant anesthesiologist.
She changed my life
I was introduced to a pt w/#cirrhosis & PPH.
She was diagnosed after being screened (see criteria Fig1)
PPH was controlled (see tx options Fig 2)
But she had a rocky time periOp.
Desperate, my mentor started imatinib based on a recent case report (Fig3)
She did better!(Fig 4)
Read 10 tweets
16 Jan 19
Hepatopulmonary Syndrome - or is Portopulmonary hypertension? What’s the diff (brief #tweetorial)
Pulm complications of #cirrhosis can be devastating. This month on rounds, I was reminded that these conditions are confusing.
#meded
Step 1:
Recognize when a pulmonary complication could be present or clinically important (4 transplant)
This is how they looked when first described:
1. Portopulmonary: Dyspnea without hypoxia (Fig 1)
2. HPS: Hypoxia (Fig 2)

Step 2:
TTE (Fig 3)
Ordering "agitated saline" echocardiography will always be funny

TTE▶️most sensitive way 2 dx HPS(Fig1)
The bubbles dont go right▶️left immediately (like with septal defects) but do after a few heart beats
Bonus: do not rely on pulse ox!(Fig2)
Screen or go 2 TTE on by symptoms
Read 8 tweets
16 Jan 19
Putting my #livertwitter #tweetorials in one place
I must have deleted my original index tweet.
(More are coming in 2019)
Read 5 tweets
7 Oct 18
What is hepatorenal syndrome?
A #Livertwitter #tweetorial

Hepatology is awesome, exciting, but also humbling.
Nowhere is that clearer than HRS, a true unmet need for patients with ascites

Aims
1. What
2. Why
3. How to prevent/treat
4. ❤️ #cirrhosis physiology
What:
1. Ascites trashes QOL & is deadly enough to merit mention in the bible(Fig1)
2. Ascites physiology damages other organs; Austin Flint said it 1st (Fig2)
3. HRS is the knockout punch of portal hypertension. What begins as elevated portal mmHg and ascites ends as HRS(Fig3)
What:
1. HRS is not rare in pts w/ascites (Fig1)
2. HRS is deadly (Fig2)
3. For a definition of terms, check out the Ascites Club (that's a thing!)
ref: gut.bmj.com/content/gutjnl…
or see my review: amjmed.com/article/S0002-… (Fig3)
Read 13 tweets
27 Sep 18
Hepatic encephalopathy in the hospital (An ode to #lactulose):
A brief #livertwitter #tweetorial
Aims:
1. Share the greatest t-shirt ever made
2. Rule out infection!
3. Laxation now! But how?

keywords: #cirrhosis, paracentesis, stool pH
1. This shirt, made by a patient, reminds us:
▶️HE is horrible, unpredictable
▶️Preventing HE is hard
▶️Dont be quick 2 label pts as 'noncompliant' - there's more to the story
▶️Our patients are awesome. Hepatology is the best

#lactuloseorcomatose
2. Think of hepatic encephalopathy as a biomarker.

For what? The answers form a mandatory checklist of sorts

1. Para to r/o SBP. Delay @ your patient's peril. (Fig1)
2. GI Bleeding?
3. UA/Blood Cultures/CXR
3. What's the Cr? Na? K?
review: nature.com/articles/s4139…
#AmJGastro
Read 14 tweets
20 Aug 18
Why is your pt's ALT (or AST) >1000?
A #livertwitter #tweetorial

Take-homes:
1. Top 3 causes of acute liver injury
2. I always say it's ischemic hepatitis; 50% of the time, I'm right every time

Brought to u by:
@tonybreu et al. What causes severe ALI?
cghjournal.org/article/S1542-…
The liver is awesome.

Yet its vocabulary is ... limited.

We can all tell when it is upset - high ALT, AST.

But that could mean anything!

So what's your specific patient's specific reason for high ALT?
First - a poll:
What's the most common cause of severe acute liver injury
(ALT or AST > 10xULN)?
Read 11 tweets