Elliot Tapper Profile picture
Sep 27, 2018 14 tweets 8 min read Twitter logo Read on Twitter
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…
3. First line therapy for hospitalized "overt" HE is lactulose

This nonabsorbable disaccharide has been used for HE for >50 years. (Fig1)
It was known even then that there had to be another mode of action beyond frequent BMs
Lactulose's mechanism of action came into focus after a 1966 trial in patients w/chronic HE
Fig1: Design - lactulose before or after sorbitol (osmotic laxative) with run-in
Fig2: HE that occurred on sorbitol could be resolved on lactulose
Fig3: The key difference: STOOL PH!
The same effect occurs after a lactulose enema.

See these data from a randomized trial of tap water vs lactulose enema in @HEP_Journal
How does lactulose lower stool pH?

The answer is that colonic bacteria metabolize the lactulose, spitting out organic acids

Check out this study from @jclinicalinvest comparing the stool output and organic acid concentration after PEG (aka golytely) vs lactulose
And here is the kicker: A little lactulose goes a long way

Even in subjects who had formed stool, lactulose still increased the organic acid concentration!
🥊 PEG vs Lactulose 🥊 The HELP RCT

This remarkable study was led by Dr. Bob Rahimi - who, as a FELLOW, enrolled 50 patients who often present in the middle of the night! #hustle

Lactulose (20-30grams TID) vs PEG Colonoscopy prep (4L)

Who wins?
PEG hastened recovery from HE (Fig1)!

Many patients also preferred the PEG to lactulose (Fig 2)
Before you pop the cork on the Golytely, check out the supplement(Fig1):
84% of PEG patients got lactulose before randomization

CLEARLY you need 2 get the bowels moving (more laxative=better)
but a little lactulose goes a long way. Stool pH not measured.
Also...what's the right dose of lactulose?

When a pt comes in with acute CHF, would we give them their home diuretic dose?

Patients admitted with HE often get ~10-20cc TID
🔥Hot take 🔥 This is not enough: That is a maintenance dose

Your pt needs an induction dose!
Unlike with PEG, you dont need 4 liters, but >20cc lactulose q6-8? Definitely!
I learned how 2 treat HE from nurses when I was an intern. We took what they were doing & standardized treatment for HE. Some extra, frequent doses make a big difference(Fig1)
In summary:
- Hepatology = the best
- Do that para! Search 4 HE triggers
- Drop that stool pH! Even a little lactulose helps
- Laxation now!! Need frequent BMs on Day 0-1 to treat Overt HE. Take your pick: extra doses of lactulose or lactulose + PEG.

Thanks for stopping by!

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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
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
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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