Elliot Tapper Profile picture
Aug 20, 2018 11 tweets 7 min read Twitter logo Read on Twitter
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)?
Chances are, in your hospital, a sky-high ALT earns six pints worth of serologic tests

A few months ago, I saw someone check Parvo

Parvo is the new EBV
But ... what ACTUALLY causes severe acute liver injury?

Check out this multicenter study (community/transplant/VA) led by THE @tony_breu - hot off the presses

Top 3:
- Ischemic hepatitis
- Stones / biliary causes
- Drugs

ref: cghjournal.org/article/S1542-…
Notice...blood tests may not find the top 3

There are 4 types of blood tests for ALI:

1: HAV/HBV/HCVtylenol
2: Things that never-ever cause ALI (Fig1)
3: Things that are occ. helpful and often misleading (Fig2)
4: Things the AGA recommends NOT testing (ceruloplasmin, Fig 3)
Knowing the true DDx tells us what 2 do

1. Drugs: Start NAC if tylenol! If not, NAC still ok (Fig1)
2. Acute CBD stones happen! (Fig2). Ultrasound vs MRCP --> ERCP.
3. Ischemic hepatitis... see act 2

Summary (Fig 3): Stepwise testing for severe ALI
Act 2:

Who gets ischemic hepatitis?

1. It's not just about hypotension!(Fig1) If it was, every patient in the ICU would have ALI.
2. 90-100% of patients w/ischemic hepatitis have CHF, almost always right heart failure (Fig1-2)
3. Indeed, 🔼ALT is a risk biomarker in CHF (Fig3)
The mechanism of ischemic hepatitis:
1. Liver has dual blood supply. 75% portal vein(5mmHg), 25% hepatic artery(Fig1)
2. CHF▶️congestion▶️venous htn >portal pressure🔽o2 diffusion in sinusoid
3. Liver arterializes▶️dependent on hep art(Fig2)
4. Transient🔽BP▶️🔥(Fig3)
Why tweet about this?

1. Ischemic hepatitis is common and deadly.(Fig1) Often unrecognized.
2. I suspect right CHF is under-recognized. Correct me if wrong
3. While you are checking liver labs, please think about ischemic hepatitis and right HF.

ref: sciencedirect.com/science/articl…
This concludes a #livertwitter #tweetorial on ischemic hepatitis. I hope you enjoyed it. Thanks as always to @tony_breu for his #meded-inspiration

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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
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
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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