Dr. Sears’s fun, fast-paced speaking style peppered with her wellness moments (and El Arroyo quotes) always make for an excellent learning experience.
Her quick recap on acute pancreatitis included that early refeeding of patients is good, with a lower length of stay and cost. She referenced the September 2022 Waterfall study from the New England Journal of Medicine, which was also highlighted in the Update in Hospital Medicine talk. The study was stopped due to harm as patients did worse in the aggressive fluid group than in the control group. We often have patients with acute pancreatitis without an obvious source such as alcohol or a stone, and she recommended remembering DIPI—drug-induced pancreatic injury—caused by steroids, antiepileptics, antihypertensives such as furosemide and losartan, codeine, azathioprine, mercaptopurine, 5-aminosalicylic acid, antibiotics such as tetracyclines, and didanosine. She also recommended a better prognostic score for pancreatitis than Ranson, APACHE-II, or C-reactive protein: the EASY (Early Achievable Severity Index).
In acute liver failure, Dr. Sears presented the results of a study in the October 2022 Journal of Hepatology, showing that carvedilol resulted in less decompensation (ascites) and mortality in cirrhosis and improved survival compared to propranolol. Propranolol can cause worse biliary perfusion and refractory ascites. Based on the CONFIRM trial, terlipressin is the preferred vasoconstrictor over octreotide or midodrine administered either as an IV bolus or continuous IV infusions in patients with hepatorenal presentations.1 It is contraindicated in patients with hypoxia, known ischemia, or worsening respiratory function. Terlipressin can be used with albumin; patients need to be on continuous oxygen monitoring; and it is usually used as a bridge to transplant. COVID-19 vaccinations were strongly recommended in cirrhosis patients—data at the Liver Meeting 2022 reported three doses had better protection, with 100% prevention of death, and 80% prevention of infection. Variceal screening was no longer recommended with endoscopy unless elastography is greater than 20 kilopascals and platelets less than 150,000, or nonalcoholic steatohepatitis with elastography 25 to 50+ and platelets less than 110,000.
One controversy she addressed was regarding anticoagulation in cirrhotic patients. The literature and her experience have recommended no fresh frozen plasma, Vitamin K, or other reversal agents in acute GI bleed, though there is non-agreement on prothrombin complex if the patient is on warfarin.2 Clots need to be treated with anticoagulation despite platelet counts. While most use proton pump inhibitors (PPI) in GI bleed, she did not recommend this for liver patients—portal hypertension is not an acid problem and results in more C. difficile infections and renal issues. Lastly, for liver patients, good protein intake was recommended with nighttime and early morning snacks, shooting for 1 gram of dietary protein per kilogram of actual weight. Less than 21.5 kcal/kg/day was linked with increased mortality in alcoholic liver disease with cirrhosis.
For the 40% of the population that suffers from functional bowel disorders, deprescribing PPI was an important component of this management, and she gave instructions on how to do this with a warning that symptoms will increase the first two weeks, but that this can be treated with H2 blockers or Tums.
Stress is strongly related to these symptoms, and mindfulness was noted as a strategy. [A side note here on wellness that I found very helpful was that when you get a patient who aggressively asks you why you cannot fix their problem, you turn and wash your hands in the sink, giving yourself a brief hand massage, and time to manage your emotions, and hopefully the patient has time to reflect on their behavior as well.] Various diets were reviewed for improving eosinophilic esophagitis, and just eliminating milk improved symptoms by 30 to 40%. Fecal transplants are showing comparable benefits to biologics for immune-mediated colitis. For constipation, using 32 Vibrant capsules (they just vibrate in the colon) doubled spontaneous bowel movements per week.
Dr. Sears has seen a large increase in acute alcoholic hepatitis during COVID-19, particularly in younger women. Online Alcoholics Anonymous has 24-hour-a-day meetings. Heavy alcohol use is considered three drinks a day in women and four in men. Other liver toxins mentioned that cause drug-induced liver injury include antibiotics and substances found in complementary and alternative medicine products. Liver injury usually presents one to three months after starting the drug or food, and mortality can be more than 50% if the agent is not stopped.
The last papers presented indicated that we need to avoid unnecessary nil per os (NPO) status. If we have fewer NPO orders, that can lead to more trust from patients. NPO is linked to falls, hypoglycemia, and increased length of stay. She reviewed the American Society of Anesthesiologists’ guidelines that eight hours of NPO are needed after a heavy meal, six hours after a light meal, and two hours after clear liquid.
References
- Biggins, Scott W, et al. Diagnosis, evaluation, and management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: 2021 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 74(2):1014-48.
- Abraham NS, et al. American College of Gastroenterology-Canadian Association of Gastroenterology clinical practice guideline: Management of anticoagulants and antiplatelets during acute gastrointestinal bleeding and the periendoscopic period. Am J Gastroenterol. 2022;117(4):542-58.
Dr. Green
Dr. Green is an internal medicine hospitalist and chief medical officer at Paris Regional Health, Paris, Texas.
