TheLiverDoc Profile picture
#ClinicianScientist Proud of serving my patients. Debunking #pseudoscience. #LiverTwitter #microbiota See #Ayurveda differently. Research: #herbals #toxicology
N.V.Ramanan Profile picture Dr Sharfaroz Profile picture The outlaw Profile picture Misha Profile picture MazM Profile picture 17 added to My Authors
Aug 6 52 tweets 15 min read
1/52
'Do you know what he loves most?'
his wife asks me

What is it?
I inquire

'When school re-opens, & children buy colorful stickers from his shop, the smile on their faces', she says,
'when he gives them some free.'

'Will he be able to do that at least?'

& my heart race. Image 2/52
In 2014, Ajith suffered from alcohol use disorder

He used to consume almost a liter of alcohol every day and come back home on all fours

Until one day, when he started developing memory loss, could not identify his wife & children & went into a state of confusion

2 wks..
Jul 31 46 tweets 16 min read
1/45
Middle aged man, James is brought for admission

Deeply jaundiced, confused, incomprehensible

His wife is desperate

Docs elsewhere gave him 3 more months of life

What did they say he has? I ask her

Alcoholic hepatitis, she says

& I think to myself - 'docs were right' 2/45

James has been using alcohol daily since last 8 years

Since last 2 years, he started drinking excessively & alone

He wakes up only to start drinking more than a liter per day

His last alcohol use was 3 days prior to current jaundice onset

He was obese and without...
Jul 30 6 tweets 2 min read
Recently diagnosed alcohol related cirrhosis, name Rakesh

Brought to my OPD for evaluation and management

Middle aged man, one child, young daughter

Wife is a clerical assistant in a Govt office, name Sindhu

Rakesh has been a heavy drinker
Has had 2 episodes of jaundice+ in the recent past

Both times mild alcohol associated hepatitis, resolved in few weeks, got back to drinking again

Consumes close to 800ml daily
Hard liquor, rum, whisky and gun

Early morning drink (eye opener)
Absolutely no insight into disease

Sold off shop to partner+
Jul 29 12 tweets 3 min read
Sadhguru's ELEVEN scientific quotes that challenged my scientific temper and changed my life 1
Jul 28 5 tweets 1 min read
This 30's something woman comes to the OPD with her jaundiced husband

They have two kids, 8y son and 4y daughter

The husband drinks close to 1 liter of alcohol every day. His last drink was this morning before coming to meet me

He has severe alcohol hepatitis
Chances of him... dying is close to 70% at six months without a transplant

He developed jaundice five days back, but continued drinking. Some days He drank and slept on the porch

Wife called the neighbors and all of them forcefully put him inside a car and got him to the hospital

He needed...
Jul 22 45 tweets 12 min read
1/ I walk up to the middle-aged woman who is terribly worried

This is the third time her husband is in the ICU

Each time, worse than the previous

This time, he is in a coma, and the reasons for him going into recurrent altered behavior remain elusive

Only one clue - cirrhosis Image 2/ Shankar, her husband has diagnosed with cirrhosis just a two months ago

At the time, he had swelling of both feet and an evaluation revealed low platelets and features of cirrhosis on imaging

Absolutely no complications of cirrhosis

Complications of cirrhosis come in stages
Jul 12 19 tweets 7 min read
Here is the master thread of my #tweetorial mega threads on real-life clinical mysteries, difficult diagnoses, tough-as-nuts patient management and every patient case that made me and my treating unit sweat it out.

*continuously updated

#MedTwitter #FOAMed 1. A young girl with mysterious liver failure and her father who wants to avoid a liver transplant.

Jul 10 54 tweets 16 min read
1/ 'There is a referred case for you', the ER doc tells me.

'How bad is it?' I ask him

'Pretty bad,' he says

'But nothing a good clinical history cant crack eh?',
I tell him confidently

'That's the problem', he shoots back, ' the patient cant speak. He's on he ventilator'. 2/ Elsewhere, the patient, Navin (name changed), a 48-year-old school teacher did not give doctors time to figure out what was going wrong

He presented with fatigue for 1 week, lacked interest in food and then, one fine day, became disoriented and the next day, landed on the..
Jul 3 52 tweets 20 min read
1/ 'There's a self referred patient for you', ER doc tells me

'Self referred?'

'Yes, husband getting her discharged from multiple hospitals looking for a diagnosis'

Self referrals are nerve-racking, I thought, as I walked in, looking at the deeply jaundiced, disoriented woman 2/ The husband, Raj is by side of her bed

He is worried sick

Elsewhere, they were advised liver transplant

Docs weren't sure what was causing liver failure,
killing his wife, Meera

All he knew was that it was acute liver failure(ALF)

ALF is a terrifying, flummoxing disease
Jun 26 54 tweets 13 min read
‘Hepatology case’?
I ask the ER doc

‘Not sure doc’, he replies

‘Severe pancreatitis, but something is off.’
I think your Unit needs to look at it

‘Liver looks coarse & thers fluid in abdomen’

& we prepare ourselves for a confrontation so sinister, we did not know we'd lose... 39y old, healthy mother of 2 children

10y pretty girl, 5y little boy

Husband works as an office staff for a large MNC

Loss of appetite was first symptom, followed by abdominal discomfort

These went on for 1mo

An ultrasound done at the time revealed coarse fatty liver...
Jun 21 5 tweets 3 min read
I think India should be proud about the most glorious stretching it has gifted to the world

But glorifying it using sick kids inhospital is kind of begging for credibility for a pseudoscientific practice that has pseudo-modernized through the ages

#InternationalYogaDay2022 Many will be surprised to see the term pseudoscience associated with Yoga. Thats bcoz u dont really know principles behind Yoga which is at best, contorted stretches to improve flexibility, nothing more

Yoga delusion
nirmukta.com/2011/10/31/the…
Yoga woo
sciencebasedmedicine.org/yoga-woo/
Jun 18 34 tweets 11 min read
Im lukin at the middle-aged man
His eyes deeply jaundiced
I was sure he saw everythin yellow

Diagnosed with severe alcohol-hepatitis (AH), docs elsewer went up to third line therapy
without any success

So here he was with me
Both of us battling an enemy hiding in plain sight... 6 wks back he started complaining of loss of appetite and fatigue

No fever, joint pains, skin rash

Tests for Covid were negative
As were other viral diseases

In a wks time, he saw his eyes turn yellow
and his urine a dark orange

He admitted to binge drinking...
Jun 16 13 tweets 6 min read
EVERYONE PLZ see this theory question
asked for Final Year Bachelor's in Ayurveda degree

Question is write short essay on
"Woman as an Aphrodisiac item"

In the next tweets, I will show the textbook which students of Ayurveda are made to study and the answer to this question... ...this is the answer that students are studying in their Bachelor's degree, instead of progressive, scientific facts that are to be useful for community and humanity

Chapter teaches how to objectify women into aphrodisiac 'items' and 'baby making factories'
Jun 16 5 tweets 5 min read
Assistant Commisioner of Police Traffic West, Kochi, has blocked entire public road for his morning walk

Morning school buses are unable to pick children from respective apartments

Children are forced to cross road between cars coming from both sides on the opposite road

1/3 Parents spoke to Officer, but doesnt budge, wants to continue his 'kingly' routine

Queens Walkway Kochi has separate jogging track & service road

But this man blocked entire public road for his morning routine, endangering kids
2/3

@TheKeralaPolice @HibiEden @kochicitypolice
Jun 15 7 tweets 3 min read
As Indian medical education system is headed towards "Integrated Medical Care" which means, scientific medicine will work along side Ayurveda and such alternative practices,

I would like to point out why this is a marvelous idea and one that will strengthen public health.... Image Middle aged man is diagnosed with reactivation of chronic hepatitis B virus infection

He was seen in 2010 with flare of hepatitis B and that settled spontaneously. An integrated medicine practitioner treated at that time.
No antivirals given, patient did well... Image
Jun 13 6 tweets 3 min read
I wish I had this Homeopath confidence

1.Self limiting🙂
2.PCOS can't be 'cured'.Probably u misdiagnosed PCO vs PCOS😑
3.Infertility due to? Infertility is not a diagnosis🙄
4.All r self limiting🥲
5.ALL pediatric issue? Hav U cured Tetrology of Fallot?

I ❤️ ur stand up comedy Image Err...but new bone formation is normal as part of fracture healing.

Did you mean the Homeopathic water remedy helped new bone formation Iike water helps plants grow?
Image
Jun 8 22 tweets 7 min read
I luk at the investigation chart & the values are off the roof

Bilirubin 18
AST 4400
ALT 3200

The middle aged patient is smiling at me &
I reciprocate

But I know his time is short bcoz
cause for his hepatitis is incredibly enigmatic

Will he take his diagnosis to the grave?... Image The patient was well until 2 weeks back when he started losing appetite and felt lethargic

He ate less & wanted to lie down all the time

He was never like this before

A farmer, very active, he worked from morning till evening in his organic farm without breaking a sweat but...
Jun 7 11 tweets 5 min read
India is well positioned to bcom global leader in traditional medicine - Minister of Ayush, India

To celebrate this, I would like to highlight recently released guidelines of:

Ayurvedic Nutritional Advocacy by Central Council for Research in Ayurvedic Sciences

in 10 tweets... 1/

Rules of diet and dining:

Points on eating small portions to strengthen digestive 'fire' so that body 'channels' remain open

Do not talk and laugh while eating

Take a bath, feel hungry and wash /feet/ also before a meal

Avoid food contaminated with grass & hair
Jun 7 8 tweets 4 min read
I'll tell you how the herbal and dietary supplements industry products harm you without you even realizing it

IN 8 TWEETS

Eg. This product

1/
Apple Cider Vinegar for "weight loss" wen highest level analysis show absolutely no effect on weight loss

verywellfit.com/vinegar-not-be… 2/ See the labeling

You may miss the "Matcha" part

And think of "The Mother" as some nature-based philosophical ingredient and not give attention to it

Bcoz the ingredient on main label mentions only 500mg Apple Cider Vinegar

- that's OK right?

No
Thats part misleading..
Jun 3 33 tweets 9 min read
Middle-aged woman enters OPD
Diagnosed wit depression since 6mo

On multiple anti-depressants/anxiolytics
Her problems do not seem to go away

But I am a Hepatologist, I tell her
– I do not treat depression

I was told ur Unit can diagnose me
Can u please atleast evaluate me?... I ask her about her family

Married with 2 children, both working

A loving husband, steady job and the couple has been social

Except since last year, she’s been feeling the blues

Does not feel like meeting people, being home helps
Home is where her heart was...
Jun 2 4 tweets 3 min read
A stable cirrhosis patient, 2 months on these herbal dietary supplements

Out of the blue, his liver cancer test is off the roof

Do herbal components stimulate and promote cancers in at risk patients?

Yes, most implicated is Aloe Vera which has ability to promote cancer... These little "sippy" blend of multiple fruits and herbs foodsupplementshop.in/product/on-on-… is rich in potential cancer causing plant chemicals and Aloe Vera too.

Here is a list of cancer causing herbs and drugs thelancet.com/journals/lanon…...