Why Is Your Pt's ALT (Or...

Metadata

• Author: @ebtapper on Twitter
• Full Title: Why Is Your Pt's ALT (Or...
• Category: #tweets
• URL: https://twitter.com/ebtapper/status/1031555677095948289

Highlights

• Why is your pt's ALT (or AST) >1000?
  A #livertwitter #tweetorial
  Take-homes:
  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?
     https://t.co/HGZtuPYF2A (View Tweet)
• 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? (View Tweet)
• First - a poll:
  What's the most common cause of severe acute liver injury
  (ALT or AST > 10xULN)? (View Tweet)
• 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 (View Tweet)
• 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: https://t.co/HGZtuPYF2A
    (View Tweet)
• 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)
  
  
  (View Tweet)
• 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
     https://t.co/5U38FlRhPY
     
     
     (View Tweet)
• 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)
     
     
     (View Tweet)
• 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)
     
     
     (View Tweet)
• 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: https://t.co/T06qkFiFOL
     (View Tweet)
• This concludes a #livertwitter #tweetorial on ischemic hepatitis. I hope you enjoyed it. Thanks as always to @tony_breu for his #meded-inspiration (View Tweet)