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Jul 10, 2018 19 tweets 8 min read Twitter logo Read on Twitter
A celebration of paracentesis: a QI #Tweetorial

For all my twitter friends who care for inpatients with #cirrhosis

Take home messages: paras for all, FFP for none
Keywords: #SBP and the #cirrhotic #coagulopathy
First - which hospitalized patient needs a diagnostic para?

Patients with ascites and:
Spontaneous bacterial peritonitis (SBP) is a deadly condition. Appropriate tx can prevent hepatorenal syndrome and death.

How many patients are asymptomatic?


In this study from Pinzello et al, 1 in 3 patients with SBP were "silent"
A silent but deadly condition is a problem if delay in diagnosis is associated with worse outcomes.

Uh-oh ... patients with SBP definitely prefer early diagnosis

See this terrifying chart from Kim et al in #AmJGastro nature.com/articles/ajg20…
Do you agree that paracentesis is important to do and do it early?
Act 2:
But - you say - my patient has an INR so we can't 🙄
Well...maybe you can

For one, the American Association for the Study of Liver Diseases (#AASLD) recommends doing a para on everyone except those in DIC and not giving plts or FFP beforehand

Why so confident?
First, bleeding is super rare and unrelated to platelet count and INR

Check out this summary of a few large-ish studies
Second, bleeding has little-to-nothing to do with PT/INR

Check out this graph of bleeding time vs PT - no relation.
This is a wild study where Dr. Ewe clocked bleeding time after a laparoscopic liver biopsy. PT does not predict!
Dig Dis Sci. 1981 May;26(5):388-93
If INR correlates with bleeding in patients on coumadin, what's the deal with #cirrhosis
The INR measures some BUT NOT ALL factors in the clotting cascade.

And its missing important parts of the story

Say what?
So this is a huge topic and I will summarize but first will refer to the masters including Tripodi and Caldwell:


I have a few points
One - all factors are altered in cirrhosis - including liver-derived pro AND anticoagulants.

Think of this picture - things are rebalanced in cirrhosis. But tenuous.

The patient can tip both ways (clot or bleeding) depending on the context

Clin Liver Dis. 2009 Feb;13(1):1-9
Two - the clotting factors from OUTSIDE the liver are higher.

Factor 8 says "dont forget about me!"

See this table from @AGA_Gastro sciencedirect.com/science/articl…
Three - and most importantly - PT assays generally lack thrombodulin; i.e. thrombin generation is not captured.

Thrombin generation is the business end of the clot cascade

And it turns out ... it is usually preserved in cirrhosis.

And sometimes it is HIGHER!
This is what happens when you put thrombomodulin in the mix

And if you look at thrombin generation stratified by INR, you get an interesting graph, like these ones. Clotting tendency looks like Factor V Leiden by these assays!
J Thromb Haemost. 2010 Sep;8(9):1994-2000
Hepatology. 2010 Jul;52(1):249-55
So elevated INR is not by itself a contraindication to an important - potentially life saving procedure

But it is a window into the wonderful world of cirrhotic physiology!

Did you find this helpful?
You may have noticed that we never talked about thrombocytopenia.

Would you like to?

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More from @ebtapper

Oct 7, 2018
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

1. What
2. Why
3. How to prevent/treat
4. ❤️ #cirrhosis physiology
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. 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
Sep 27, 2018
Hepatic encephalopathy in the hospital (An ode to #lactulose):
A brief #livertwitter #tweetorial
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

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…
Read 14 tweets
Aug 20, 2018
Why is your pt's ALT (or AST) >1000?
A #livertwitter #tweetorial

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?
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
Jul 25, 2018
Introducing the “The Hepatologist’s CBC”

A #cirrhosis #tweetorial all about the platelet

- Identify cirrhosis based on blood tests-
- Understand why platelets are low in #cirrhosis
- Describe the plt’s role in the #cirrhotic #coagulopathy

The hepatologist's dream:
identify patients with cirrhosis before complications like HCC and variceal bleeding.

Enter the platelet count
Shout out to JAMA's Rational Clin Exam Series & Udell et al's big beautiful systematic review ncbi.nlm.nih.gov/pubmed/22357834
Platelets are low in #cirrhosis.
We can use this to our advantage - even sparing biopsies.

Easy to do. E.g. Google: FIB-4
(ref aasldpubs.onlinelibrary.wiley.com/doi/abs/10.100…)

There are many platelet-based scores to help ID cirrhosis.
(review: ncbi.nlm.nih.gov/pubmed/2883446
Read 14 tweets
Jul 16, 2018
What's the deal with Ammonia in hepatic encephalopathy?
A #cirrhosis QI #tweetorial

Try to answer this question while also showing
1) Ammonia levels dont matter
2) U should not restrict protein in patients with HE

Keywords: "ammonia hypothesis", sarcopenia
First, a poll:
Does Ammonia cause hepatic encephalopathy?
How did NH3 get involved with #HE in the first place?

Step 1: In 1877 Eck develops the first successful vascular anastamosis, a portocaval shunt. ncbi.nlm.nih.gov/pubmed/9186464
Step2: Pavlov improves it
Step3: Dogs get goofy after eating meat:"Meat stupor"
Step4: What's up with meat!?
Read 26 tweets

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