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Jul 25, 2018 14 tweets 10 min read Twitter logo Read on Twitter
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
Be like Britain:
Even in their guidelines for the evaluation of elevated ALT, the brits make a plea for looking at platelet-based scores the minute you realize ALT abnormal (ncbi.nlm.nih.gov/pmc/articles/P…)
Act 2:
So why are platelets low in #cirrhosis?

At least 3 reasons:
- Splenic pooling
- Increased destruction
- Low production
1: "The spleen is a platelet hotel"
- Sir William Osler (personal correspondence)

Portal hypertension ▶️splenomegaly ▶️platelet pooling

(Osler was one of the first to link cirrhosis and low plts)
You can shake the platelets loose from a spleen

Temporarily: super cool 1966 study from Aster (Fig 1)
-Radiolabel platelets
-inject epi(!)
-radiotracer shifts spleen to blood

Permanently: Splenic Embolization (Fig 2)
2. Cirrhosis is a pro-inflammatory state which is bad for platelets

Endotoxin from the gut circulates, stimulating immune responses.
As total IgG 🔼, so does anti-platelet antibodies (Fig1)
Reduced spleen volume 🔽 anti-plt IgG (Fig2)
Reduced endotoxin may 🔼plts (Fig3)
3. The hormone for platelet growth - thrombopoetin (TPO) - comes from, you guessed it, the liver

Fig 1: replace the liver, 🔼TPO, 🔼platelets
Fig 2: TPO levels and plts by stage of fibrosis
Fig 3: 🔼TPO activity, raise plts
Act 3:
So what does this have to do with the cirrhotic coagulopathy?
Platelets rule!
The platelet is the MVP of the first phase of hemostasis:
Need it to stick, aggregrate, and activate on the vessel wall.
It even catalyzes the coag cascade!(Fig 1)
In cirrhosis, thrombin generation is preserved, independent of INR, until plts are superlow(Fig2)
Platelets are quantitatively AND qualitatively defective in cirrhosis

1. Cirrhosis 🔽 platelet adhesion (fig 1)
2. Cirrhosis 🔽 platelet aggregation in response to stimulus (fig 2-3)
3. Cirrhosis platelets 🔽activation (they are metabolically "exhausted")(Fig4)
The platelet's role in the cirrhotic coagulopathy summarized in this snapshot @JHepatology
Well I hope you enjoyed this platelet rich tweetorial. And I hope it helps you identify #cirrhosis.
Despite all this coagulopathy talk, some parting words.
None of this should stop you from:
Fig1: Doing that para
Fig2: Banding that varix
Fig3: Placing that central line

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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 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
Jul 10, 2018
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"
Read 19 tweets

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