Elliot Tapper
@ebtapper
Followers
38,785
Following
757
Media
2,328
Statuses
11,827
Hepatologist @michiganliver @vaannarbor ; #cirrhosis ; encephalopathy; frailty; quality improvement; father; husband. #livertwitter Co-EIC of @HepCommJournal
Ann Arbor, MI
Joined September 2011
Don't wanna be here?
Send us removal request.
Explore trending content on Musk Viewer
Rio Grande do Sul
• 516744 Tweets
#MiamiGP
• 452908 Tweets
Lando
• 450267 Tweets
GW最終日
• 176979 Tweets
Verstappen
• 144909 Tweets
Menotti
• 143044 Tweets
Cinco de Mayo
• 135879 Tweets
MARTIN AL 9009
• 117810 Tweets
McLaren
• 96956 Tweets
Mauro
• 73165 Tweets
Bahia
• 63800 Tweets
Hugo
• 59697 Tweets
連休最終日
• 58859 Tweets
Panamá
• 54235 Tweets
Sporting
• 51612 Tweets
DRAKE DROPPED
• 47909 Tweets
Mulino
• 44992 Tweets
Sainz
• 43207 Tweets
大谷翔平
• 36790 Tweets
ゴールデンウィーク最終日
• 36750 Tweets
Piastri
• 33449 Tweets
#この漫画知っている人で100いいね
• 27810 Tweets
Rony
• 18815 Tweets
Gaby
• 17888 Tweets
Tom Brady
• 14288 Tweets
振替休日
• 13939 Tweets
Estevão
• 13709 Tweets
大谷さん
• 12651 Tweets
Lombana
• 12581 Tweets
MOTOROLA FURIOSO
• 12370 Tweets
Achievement unlocked:
Just had a paper rejected from the journal where I am editor-in-chief
364
1K
25K
1/
WHERE does ascites come from?
HOW do diuretics treat ascites?
ARE you ready for a
#tweetorial
?
#livertwitter
#medtwitter
#MedEd
52
787
3K
An older man comes to the ED with abrupt onset nausea, & diarrhea
He is joined by her daughter whom he is visiting from abroad
Testing is below
The diagnosis is unclear
Until his daughter got just as sick too
🧵
#livertwitter
#liverstory
#MedTwitter
69
441
2K
An $800 out-of-pocket cost at the pharmacy is an adverse event.
30
156
2K
The hepatitis B vaccine is amazing.
It also has a wild backstory
Want to hear it?
A
#tweetorial
1/
#livertwitter
#MedTwitter
26
463
1K
A patient with diabetes and recent NSTEMI treated with stent, clopidogrel, and atorvastatin ~2 months ago is transferred from OSH with ALT 1500, bilirubin 15
The leading diagnosis is statin liver injury
But that's not what it is.
Not at all
🧵
#livertwitter
#liverstory
37
330
1K
NAFLD no longer - get to know MASLD and MASH
The nomenclature for metabolic liver disease has been changed. See below for the family tree of steatotic liver disease
Link:
#medtwitter
#livertwitter
17
505
1K
1/
WHY are steroids used for alcoholic hepatitis?
SHOULD we?
WHAT is the deal with prednisolone vs prednisone?
WHERE did the discriminant function come from?
ARE you ready for a
#tweetorial
#livertwitter
#medtwitter
#meded
#cirrhosis
34
450
1K
1/
HOW does gabapentin work?
DOES gabapentin work?
WHY is gabapentin so shady?
Join me for a
#tweetorial
?
Keywords: Glutatmate, Asterixis, Alcohol-use disorder
#livertwitter
#MedTwitter
#meded
31
365
1K
Have you ever wondered ... how beta-blockers treat
#cirrhosis
?
Here's a
#tweetorial
featuring:
1⃣Pathophys!
2⃣controversy!
3⃣Cheap, life-saving interventions!
#livertwitter
#gitwitter
#meded
1/
19
395
1K
1/
WHY does
#cirrhosis
cause palmar erythema?
HOW is estrogen involved?
WHO is ready for a
#tweetorial
?
Let's talk hormones, the liver, the impact of imbalanced testosterone/estrogen, & the history of spironolactone
#livertwitter
#medtwitter
#MedEd
25
278
971
It’s a landmark in the history of NASH (MASH)
A positive trial: less fibrosis, less inflammation, lower LDL
Something to celebrate
#livertwitter
14
287
909
What's the deal with Ammonia in hepatic encephalopathy?
A
#cirrhosis
QI
#tweetorial
Aims
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
38
408
905
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
Aims
1. What
2. Why
3. How to prevent/treat
4. ❤️
#cirrhosis
physiology
24
364
894
31
262
852
Potassium and hepatic encephalopathy
1⃣K-wasting diuretics can trigger HE
2⃣K-wasting diuretics can⬆️ammonia(Nh3)
3⃣K repletion can⬇️nh3
Why?
⭐️Renal recapture of K+ by H+/K+ exchange needs glutamine's Nh4+ which gives h+ AND nh3
So, if HE:
1⃣fluids
2⃣replete K
#livertwitter
19
280
827
Why patients with
#cirrhosis
get infections - and why those infections are so deadly
An authoritative
@nejm
Review by
@JasmohanBajaj
#livertwitter
5
233
815
What's the deal with ... Gilbert's syndrome?
Unconjugated bilirubin deserves its own
#tweetorial
Featuring:
🟨Why?
🟨Is it bad or...PLOT TWIST...good!?
🟨What to do about it?
🏆The most 🍌🍌trials ever conducted
#livertwitter
#meded
#MedTwitter
1/
39
255
721
Remarkable
@theliverdr
has had his account suspended in India for his work on preventing drug induced liver injury from herbal supplements. The company has gotten
@X
to this. This is censorship
Akin to having a beer company cancel an account that publishes on
#cirrhosis
So
@HimalayaIndia
got an ex-parte order from a Civil Court in Bangalore instructing
@X
to withhold his account.
Here is the order:
ex-parte:
@theliverdr
wasnt even given an opportunity to present his case
1/n
96
827
2K
18
233
687
This RCT is bananas
Lactulose vs PEG for colonoscopy prep
Lactulose didn’t just win, it murdered PEG. Patient preference, AEs, prep quality and ADR.
Who would have thunk?
32
136
685
Are you interested in where the idea of lactulose to treat hepatic encephalopathy came from?
#cirrhosis
11
163
686
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?
31
333
679
1/
Why do we use NAC (n-acetylcysteine) for tylenol overdose?
A
#tweetorial
tylenol is also known as paracetamol, acetaminophen, APAP
#livertwitter
#meded
#medtwitter
12
219
636
A patient with
#cirrhosis
and hepatic hydrothorax was admitted to an ICU 3 times for severe shortness of breath and hypoxia for urgent thoracentesis and diuretics
So we put in an indwelling catheter
Within weeks the output was minimal
What happened?
🧵
#livertwitter
22
169
637
What is
#cirrhosis
?
This is for patients & anyone who has ever asked:
❓ What is it
❓ Where did it come from?
❓Why do I feel this way?
❓ Am I dying?
A
#livertwitter
#tweetorial
27
238
628
Dear Medicine Residents,
inpatient is only a sliver of hepatology
Come 2 my clinic
See people w/
cured HCV
normal Cr after HRS
normal bili after alc hep
ppl w/o a drink in a year on therapy
ppl w/NASH who lost 80lbs
ALT 1000➡️19 from autoimmune
please add,
#livertwitter
36
53
624
#Coffee
consumption is associated with healthier livers
In this national study,
@sniezenMD
shows that caffeinated coffee - not decaf or tea - is associated with lower liver stiffness by fibroscan
#livertwitter
#medgrind
@AGA_CGH
34
215
615
Never too late
There are people who had jaundice, ascites, encephalopathy, and variceal bleeding 2-3 years ago who are, today, loving life, working, and having ultrasounds read as "normal" with no red whatsoever in their lab panels
All because they stopped drinking alcohol
14
106
615
HepatoADrenal syndrome
Say WHAT?!
⌚️It's
#tweetorial
o'clock
Be prepared to:
1⃣Define adrenal insufficiency of critical illness
2⃣never look @ a lipid panel the same
3⃣respect how sick ppl w/
#cirrhosis
get
#MedTwitter
#meded
#livertwitter
1/
28
219
591
Pathophysiology of
#cirrhosis
complications
#livertwitter
Beautiful art by
@IDrawPicsAllDay
in
@JAMA_current
2
158
533
Why does upper GI bleeding trigger hepatic encephalopathy?
Because 🩸proteins lack BCAAs!
Nutritionally useless!
So they massively spike ammonia generation in the gut.
Even wilder...if you infuse isoleucine, you fix the problem.
See:
#livertwitter
3/4
So why does blood cause this bump in urea and increase in BUN/creatinine ratio, whereas a steak dinner does not?
Because blood has poor BIOLOGICAL VALIUE (the protein is poorly utilized by the body).
The LOWER the biological value of a protein, the HIGHER the urea.
7
5
82
4
101
520
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
26
253
496
1/
HOW long do you live with
#cirrhosis
?
WHERE did MELD Score come from?
WHAT is a "TIPS"?
ARE you ready for re-
#tweetorial
#livertwitter
#medtwitter
#meded
17
194
495
True story
There have been 15 trials of tooth brushing in the ICU
and those trials have demonstrated fewer pneumonias and icu deaths
In
@JAMAInternalMed
12
145
491
What's the deal with pain control in
#cirrhosis
?
A
#meded
#tweetorial
with QI undertones
Aims:
👍Tylenol
👎NSAIDs (mostly)
🤯Pharmacokinetics in ESLD
🔪Tramadol
If this is a confusing topic for you, you are not alone!
Join me as we try 2 sort a few things out
#livertwitter
16
224
467
Prevention, treatment, & symptom management of
#cirrhosis
This HUGE review has everything & was fun to write with my liverfriends
eg
1⃣Disease modification (AUD tx, NSBB)
2⃣Chemoprevention
3⃣Mgmt of ascites, HE
4⃣Cramps, itching, fatigue
Free:
#livertwitter
11
135
465
Introducing the “The Hepatologist’s CBC”
A
#cirrhosis
#tweetorial
all about the platelet
Aims:
- Identify cirrhosis based on blood tests-
- Understand why platelets are low in
#cirrhosis
- Describe the plt’s role in the
#cirrhotic
#coagulopathy
#livertwitter
13
201
456
I have grown to ❤️IV iron
This is a nice review on the when, why and the how to fill the iron tank
@JosephineCool1
@FreedoBaggins
6
126
457
RIP FFP
Devastating study for FFP: does not normalize coagulation function and often makes it worse
#cirrhosis
Link:
25
170
443
Addressing low potassium is part of supportive care for hepatic encephalopathy
🧵
#cirrhosis
#livertwitter
6
94
440
I have something like 2-3 dozen patients who transferred care to me at the VA after losing their insurance.
Naturally, they are disappointed to meet me!
But I have a surprise for them.
We will provide the highest quality care they can receive
10
17
444
Everything you want to know about TEG /ROTEM
Authors:
@JanHartmannMD
@HermelinMD
@JerroldLevy
#medtwitter
&
#livertwitter
4
141
441
A dream:
A recommendation to not transfuse FFP or platelets before routine procedures in
#cirrhosis
(including para, thora, and banding) that is co-signed by societies representing gastroenterology, radiology, anesthesiology, and pathology
With me?
44
97
433
Another awesome study showing what INR really means in
#cirrhosis
🔥key messages🔥
1️⃣INR does not measure thrombin generation! This is normal or HIGH in cirrhosis
2️⃣High INR is actually associated with a PROthrombotic state!
Open access:
#livertwitter
11
155
430
I re-read this when I was 5 years into my first faculty position
And you should too
14
51
421
An OSH Hospitalist called me to tell me they were caring a for a patient of mine.
I thanked them for excellent care, we made subtle changes to the plan & discussed postdischarge strategy
Cost: 120 seconds
Benefit: teamwork, improved care, my ❤️warmed
#cirrhosis
#livertwitter
11
10
422
Door to prednisone time for alcohol-associated hepatitis...
doesnt matter
Take your time.
Rule out infection.
Sit down and hammer out a plan for the AUD.
Feed the patient.
#livertwitter
12
54
412
I visited
@AIGHospitals
in 🇮🇳. They are doing amazing work at a scale that boggles the American mind. With amazing efficiency.
We often think we can teach lower middle income countries quality and excellence. Maybe we can learn more from them.
16
79
403
/End
This concludes a
#tweetorial
on ascites formation/treatment. Thank you for reading. I hope you enjoyed.
🙏to
@jaumebosch9
and
@BloomPringle
for their input
If interested, please see below for my 'ascites' menu
31
59
397
When I was a med student, I ❤️surgery rotations. I did extra. A vascular surgeon tried to get me to do the vascular residency
“You wanna spend your life adjusting diuretics?”
Turns out, adjusting diuretics is some of the funnest & most rewarding parts of my week
#livertwitter
6
13
394
Cirrhosis and portal hypertension features a super activated RAAS system
With all that vasoconstriction, what is keeping the glomerulus open?
Prostaglandins
If so, What happens if you give NSAIDs?
1️⃣diuretics stop working
2️⃣fluid builds up
3️⃣AKI
If ascites, don’t use NSAIDs
Precarious cirrhotic hemodynamics: Like driving w/one🦶on the gas, one on the brakes
(CO=HR*SV)
1. The gas pedal: Splanch pooling 🔽SV; ❤️🔼HR & contractility
2. The tank: To🔼SV we🔼ADH,Aldo
3. The brakes: RAAS/catechole r good, till they aint
Empty tank▶️all brakes▶️HRS
0
12
33
3
116
392
What is asterixis?
👋Described~60 yrs ago by Adams/Foley
👋Methods:60pts w/impending hepatic coma vs controls
👋Flapping flexion/extension, best @ the🤚but happens even 2 the 👁️lids! Has intervening tremor (mini-asterixis)
Look 4 it while checking handgrip!
#livertwitter
1/4
12
158
389
Paradigm shifts in portal hypertension
from THE
@ggarciatsao
and
@JuanAbraldes
#LiverTwitter
#cirrhosis
14
126
389
Pickle juice sips can stop muscle cramps and improve cramp severity in
#cirrhosis
: The PICCLES RCT
Why we did this study?
1⃣Cramps are common
2⃣Cramps trash quality of life
3⃣Treatments are 💩
Paper:
#LiverTwitter
26
96
388
Ammonia levels do not correlate with severity of encephalopathy or time to resolution of encephalopathy
#cirrhosis
#EASLCongress
#LiverTwitter
11
66
388
Many patients with
#cirrhosis
have abnormal blood counts
Low platelets are most common
(Sequestration, ⬇️tpo, ⬆️destruction)
But so are low red and white cells
The yield of bone marrow biopsy for myelodysplasia is <1%
#livertwitter
6
152
378
Hot take: Methotrexate does not cause liver fibrosis
It’s ok to be cautious (periodic fibroscan). It’s ok to use MTX initiation as a trigger to look for fibrosis in at risk people (eg diabetes). But Time to turn the page
@EdmondAtallah
#livertwitter
13
136
380
Hot SBP tip: You should do a repeat paracentesis at 48 hours to see if the neutrophil count is improving
◽️might discover resistant infection
And now new paper in
@AGA_CGH
:
◻️%decline in PMN may inform prognosis
#LiverTwitter
#cirrhosis
21
103
369
1/
Why is vibrio vulnificus so bad for people with liver disease?
🤯The answer could blow your mind!🤯
Join me for a
#tweetorial
:
Act 1: Epi of v. vulnificus: What’s the deal with oysters?!
Act 2: Mechanism
#cirrhosis
#livertwitter
#idtwitter
17
146
370
19
88
368
If a patient might die during their hospitalization, call their family/friends. And after that, let their outpatient team know. We have been through a lot together and would appreciate the opportunity to say goodbye
#medtwitter
12
22
363
The dose-dependent magic of Lactulose
From prebiotic to detoxifying agent. A great review
#livertwitter
#cirrhosis
#gitwitter
6
112
359
RIP FFP
In patients undergoing variceal banding in spain neither FFP for INR>1.5 nor platelet transfusion for count <50 influenced the risk of bleeding
Bleeding occurred in 2.2% of procedures
Congrats,
@acv69cardenas
!
#ILC2020
#livertwitter
11
143
358
🚫end-stage liver disease
Let’s just stop using this term
👉can upset patients
👉always imprecise
👉often incorrect
16
47
358
Everything you need to know about coagulation tests
An absolutely awesome accomplishment
From: Drs.
@ElbCarolyne
@sholzberg
openaccess:
#medtwitter
#livertwitter
4
140
356
Systematic reviews and meta-analyses are not the highest level of evidence
34
53
351
My patient has HE. Should I check an ammonia?
#cirrhosis
New
#AmJGastro
studies (fig1-2) show:
Ordering ammonia
🚫change in lactulose dose
🚫change in LOS, ICU use
Ammonia levels
🚫association w/LOS/ICU/Survival
🤪labile, variable
Fig3: Proud 2 write editorial with Bob Rahimi
19
161
344
What to do when you see a high ferritin?
1️⃣top causes are alcohol, metabolic syndrome, chronic inflammation.
If none:
2️⃣high Tsat? Check HFE gene
3️⃣MRI can show u where iron is
4️⃣if none of 1️⃣ or 2️⃣, think about ferroportin
#livertwitter
3
123
347
The FDA has approved Resmetirom
First approval for NASH (MASH)
Friday thought: Next week the FDA is expected to approve the first drug for NASH (MASH)
2
16
121
7
84
346
#livertwitter
stop what you are doing and read
@nejm
CONFIRM
ATTIRE
And an editorial from
@ggarciatsao
5
98
341
The ATTIRE trial showed that raising the albumin level with an albumin infusion didn’t protect patients from risk, and caused harm
This trial and the investigators, Drs China and O’Brien are so inspiring. Have followed this project for years, waiting to see it in
@NEJM
8
86
342
Best practice recommendations on the use of albumin and vasoactive medications for patients with
#cirrhosis
Led by THE
@ggarciatsao
in
@AGA_Gastro
#livertwitter
5
118
340
Obstetrics Hepatology
🤝
Our patients
Scare most
Other Doctors
14
20
334
1/
WHY is there a BABOON in my room?
A
#tweetorial
about the outcomes of hepatic coma, how far we have come, and how wild things got along the way
#livertwitter
12
123
327
Guidelines are unanimous;
For look risk procedures like paracentesis we need not check INR and should not give FFP
Liver, gastroenterology, hematology, and interventional radiology societies agree
So why the variation in managing “the cirrhotic coagulopathy”?
🧵
9
106
334
The natural history of
#NAFLD
A landmark study in
@nejm
Big picture: need to identify people
#cirrhosis
. That’s where outcomes suffer
4
94
333
Management of ascites
Spiro up to 400mg + a loop, right?
What if I told you that practice varies substantially across the world? What if I told you that in 🇯🇵if people don’t respond to 25-50 of spiro and 20-40 lasix they go right to TOLVAPTAN
16
89
327
Ammonia levels corollate with neither severity of hepatic encephalopathy nor time to resolution of encephalopathy in this randomized controlled trial
From:
@JasmohanBajaj
In:
@AGA_CGH
#livertwitter
12
84
329
ATTIRE RCT: no benefit found from infusing albumin for the indication of low albumin in hospitalized
#cirrhosis
A great trial. A sad result.
We should all be thankful to
@DrLChina
for this effort and the many years of excitement inspired by her work
#ILC2020
#livertwitter
14
116
325
What to do when admitting a patient with lower GI bleeding
🔥New, awesome guidelines from
@SenguptaNeil
🔥CTA if ongoing bleeding
🔥continue aspirin for secondary ppx
🔥resume anticoag, 🚫ffp
And more
5
107
323
No further research needed
Incidence of bleeding varices after TEE =0.8%. Roughly the same rate as - I imagine - colonoscopy, slit lamp examination, and voting in a school board election
Normalize not delaying care for ppl with
#cirrhosis
#livertwitter
5
88
324
Did you know?
Albumin increases plasma volume by more than 2x.
200ml≈430ml
This can be good. Or bad!
And this explains why the hematocrit often drops after albumin is given
#livertwitter
3
65
324
Ammonia levels can be high in most people with
#cirrhosis
and do not correlate with level of consciousness
#livertwitter
, 1953
7
70
316
Q: What's the harm in a little FFP?
#cirrhosis
A: The potential to *double* the portal pressure
What FFP doesnt do:⬆️coagulation function
What FFP does do: ⬆️blood volume/pressure
Why this matters: pressure causes variceal bleeding
#livertwitter
17
95
305
Some news
#LiverTwitter
We’re excited to announce the new Co-Editors-in-Chief for AASLD’s international, open access journal Hepatology Communications (
@HepCommJournal
). Please welcome Dr. Wong (
@cw_lab
) and Dr. Tapper (
@ebtapper
)! Their term begins January 2023.
14
12
142
61
9
299
Wilson Disease is caused by mutations in the ATPB7 gene.
The prevalence of WD in Costa Rica is amongst the highest in the world.
Dr Vargas-Navarro came to
#ddw2022
to present on a novel variant he detected in Costa Rica
#LiverTwitter
6
39
299