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
1⃣Healthy person gets labs. Bili 2.4, >80% indirect
2⃣Student studies all🌙, forgets 2 eat.
In AM,👀slightly 🟨
👉3% of🌎has bili>1.4mg/dL (fig1)
Many things⬆️indirect bili:
👉Only 1⃣ makes bili⬆️w/fasting (Fig2)
Who?1⃣Described c1901. Hilarious paper
(🙏google translate, my🇨🇦franglish education)
(the thing that 'conjugates' bili)
Why?3⃣Base pair insertion in UGT1A1 promoter
(#TATAbox, the gene that makes UDPGT)
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)
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
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?
🤯Pharmacokinetics in ESLD
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
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
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)
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
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)
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
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)
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