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ebtapper's profile
Elliot Tapper
Elliot Tapper
Elliot Tapper
Verified account
@ebtapper

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Elliot TapperVerified account

@ebtapper

Hepatologist @michiganliver @vaannarbor; #cirrhosis; encephalopathy; frailty; quality improvement; father; husband. #livertwitter

Ann Arbor, MI
uofmhealth.org/profile/4313/e…
Joined September 2011

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    Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

    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

    6:20 PM - 15 Jul 2018
    • 350 Retweets
    • 752 Likes
    • Nick Gowen Anant Gupta Aysha Aslam Alexander Chaitoff Tarik Babar fede mileo MD TEQN Dave Krasinski Sandeep_59
    35 replies 350 retweets 752 likes
      1. New conversation
      2. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        First, a poll: Does Ammonia cause hepatic encephalopathy?

        1 reply 3 retweets 18 likes
        Show this thread
      3. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        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. https://www.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!?pic.twitter.com/XYsb3t2put

        1 reply 3 retweets 16 likes
        Show this thread
      4. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Enter McDermott and this 100% bananas paper from 1954:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1073522/?page=1 …

        2 replies 1 retweet 16 likes
        Show this thread
      5. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Digression: McDermott was awesome: War hero, fixed Muhammad Ali's hernia, revolutionized liver surgery Here is his obit:https://www.nytimes.com/2001/07/25/us/william-v-mcdermott-84-combat-surgeon-and-teacher.html …

        3 replies 2 retweets 23 likes
        Show this thread
      6. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        So, McDermott cared for a man with painless jaundice. In the OR: A 5cm pancreatic cancer with superior mesenteric vein involvement. To resect in 1 stage, he smacked the portal vein onto the inferior vena cava- Eck fistula! He pub'd this story in 1952: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1802351/?page=4 …pic.twitter.com/GPDg3M2E04

        1 reply 2 retweets 12 likes
        Show this thread
      7. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Then the patient keeps getting readmitted for bizarre "irrational" behaviour which occasionally progresses to coma Everyone was stumped So they studied him to figure it out. It took 6 months #NoIRB

        1 reply 2 retweets 21 likes
        Show this thread
      8. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        They noticed he would get confused after eating meat Could this be "meat stupor"? What's in meat? Amino acids and NH3 containing stuff! To summarize, the highlights: First they fed him urea -->HE (Urea --> Ammonia) So they fed him ammonia -->HE Thus Ammonia -->HE. QEDpic.twitter.com/k59JGhKG4n

        Journal of Clinical Investigation
        1 reply 1 retweet 28 likes
        Show this thread
      9. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Are you interested in what (specifically) ammonia does in the brain? Lots of bad things Let me send you to a few references: https://www.ncbi.nlm.nih.gov/pubmed/10728803  @JHepatology https://www.ncbi.nlm.nih.gov/pubmed/12668989  @HEP_Journalpic.twitter.com/DJjlYj5xOV

        1 reply 10 retweets 51 likes
        Show this thread
      10. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        So ammonia causes HE. There, I said it But is it the whole story?

        2 replies 2 retweets 12 likes
        Show this thread
      11. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Time for Jules Stahl and this 25 page single-author paper in @AnnalsofIM 1963 Turns out, Ammonia levels have nothing to do with grade of HE We knew this in 1963! http://annals.org/aim/article-abstract/678478/studies-blood-ammonia-liver-disease-its-diagnostic-prognostic-therapeutic-significance …pic.twitter.com/K01SXEUWsq

        2 replies 14 retweets 58 likes
        Show this thread
      12. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Still true in 2003! https://www.ncbi.nlm.nih.gov/pubmed/12637132  Low levels usually good but even 1 in 13 people with Grade 4 HE (coma) have stone-cold normal NH3. And an ammonia level of 150 could mean anything from no HE to coma.pic.twitter.com/AhBzvPkmPl

        2 replies 10 retweets 41 likes
        Show this thread
      13. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Somewhere, someone is doing sudoku with an ammonia of 210 just to prove a point

        5 replies 22 retweets 112 likes
        Show this thread
      14. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        HE is a clinical diagnosis. NH3 levels just cannot diagnose or grade HE. But why?

        3 replies 10 retweets 44 likes
        Show this thread
      15. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Pts w/cirrhosis & portal htn circulate bacteria from the gut. This causes inflammation Inflammation enhances diffusion of NH3 into the brain (review: https://aasldpubs.onlinelibrary.wiley.com/doi/epdf/10.1002/hep.23367 …) Don't forget: lots of HE is PRECIPITATED by what, u guessed it, infections (inflammation!)pic.twitter.com/uW4AQoEUrh

        1 reply 17 retweets 62 likes
        Show this thread
      16. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Cool study: Shawcross induced hi-NH3 - a la McDermott, by infusing ammonia salts This led to 🔽 cog function Now, Abx 🔽 inflammation Sp they gave Abx which 🔽 inflammation Then they🔼 NH3 ...but there was no cognitive dysfunction! https://www.journal-of-hepatology.eu/article/S0168-8278(03)00545-2/fulltext …pic.twitter.com/RBHSWb6rEp

        EASLnews
        1 reply 9 retweets 39 likes
        Show this thread
      17. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        One major reason the levels are useless: We have no way of accounting for the impact (and amount) of inflammation.pic.twitter.com/l3lgMGcWNc

        1 reply 4 retweets 58 likes
        Show this thread
      18. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Act 2: Ammonia is bad and I certainly dont want to cause meat stupor! Should I ask my patient with cirrhosis to eat a low protein diet?

        1 reply 1 retweet 16 likes
        Show this thread
      19. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Although NH3 levels are far from perfect, we definitely want to protect our brains from high NH3 If your liver is not working and the portal HTN is shunting blood We need a second line of defense We have one: It's the muscle!

        2 replies 2 retweets 25 likes
        Show this thread
      20. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Skeletal muscle accounts for >50% of NH3 metabolism in healthy people, even more in patients with cirrhosis. Lockwood followed radiolabelled NH3 to the muscle (JCI 1979;63); Olde-Damink confirmed the role of muscle in many cool studies (e.g. Hepatology. 2002;36:1163)pic.twitter.com/7lQg645S8N

        1 reply 5 retweets 34 likes
        Show this thread
      21. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        What happens when NH3 gets to the muscle? NH3 gets converted to glutamine at the price of a branch-chain amino acid (produced from muscle breakdown) NH3 detox by the muscle is a catabolic process!pic.twitter.com/4F1MbhQOLP

        2 replies 6 retweets 39 likes
        Show this thread
      22. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        Restricting dietary protein is a great way to exacerbate catabolism and #sarcopenia in patients with cirrhosis

        1 reply 10 retweets 62 likes
        Show this thread
      23. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        That's why patients with HE should have >1 g protein / kilogram body weight. NH3 may rise after a protein-rich meal ... but it is safe RCT: https://www.ncbi.nlm.nih.gov/pubmed/15246205  RCT: https://www.ncbi.nlm.nih.gov/pubmed/18627001  Guideline:https://www.ncbi.nlm.nih.gov/pubmed/16707194 

        2 replies 11 retweets 74 likes
        Show this thread
      24. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        So the next time you see a patient with cirrhosis are you going to check ammonia level?

        3 replies 1 retweet 21 likes
        Show this thread
      25. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        And when you see them, are you going to recommend a low protein diet?

        2 replies 1 retweet 26 likes
        Show this thread
      26. Elliot Tapper‏Verified account @ebtapper 15 Jul 2018

        I hope you enjoyed this. Wanted to thank @tony_breu for his inspiration. If you are interested in more stuff about ammonia, here's a plug for our paper "Refining the Ammonia Hypothesis" in @MayoProceedings https://www.sciencedirect.com/science/article/pii/S0025619615002177 … with @Vilas_Pat and @ZGordonJiang

        22 replies 23 retweets 178 likes
        Show this thread
      27. End of conversation

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