GiT Updates and More

Refractory Celiac disease

Causes of Ascites

A patient with cirrhosis and altered mental status does not need a head CT 🧠🚫 New study: high CT utilization, zero yield 📉🔍 Link 🔐

Chronic non infectious diarrhea .. JAMA REVIEW

Cholestatic liver disease

Cholestatic liver disease

🧠 Ammonia in liver failure is not just a lab value. It’s a brain toxin. And in the ICU… it can kill. 🔬 Key concept: 👉 Hyperammonemia = central driver of neurological deterioration Not just a marker, a mechanism ⚠️ What ammonia really does: • Crosses the blood-brain barrier • Accumulates in astrocytes • 👉 Causes cerebral edema + intracranial hypertension • 👉 Can progress to brain herniation 📊 Clinical impact: • Ammonia >150 µmol/L 👉 ↑ risk of: • Hepatic encephalopathy • Cerebral edema • Mortality 🧬 But it doesn’t stop at the brain: 👉 Hyperammonemia also causes: • Immune dysfunction • Increased infection risk • Multi-organ failure trigger 🧠 ALF vs ACLF — not the same disease 🔴 Acute Liver Failure (ALF) • Rapid hepatocyte loss • 👉 Higher ammonia peaks • 👉 Higher risk of brain edema 🟠 ACLF • Chronic adaptation • 👉 Less cerebral edema • 👉 More systemic organ failure 📉 Important ICU insight: 👉 Normal ammonia ≠ exclude encephalopathy 👉 But high ammonia = strong prognostic signal 🧪 Measurement pearls: • Arterial > venous • Serial values > single measurement • Affected by: - Infection - GI bleeding - Sarcopenia - Renal failure 💊 Treatment is multi-targeted: 🟢 Gut reduction • Lactulose • Rifaximin 🟡 Metabolic pathways • L-ornithine-L-aspartate 🔴 Clearance • CRRT → most effective sustained removal • IHD →more clearance but worst survival! 🚨 Key ICU takeaway: 👉 In liver failure, ammonia is: • A neurotoxin • A prognostic marker • A therapeutic target 🎯 Clinical mindset shift: Don’t just ask: 👉 “What is the ammonia level?” Ask: 👉 “What is the brain risk right now?”

Treatment of Refractory Constipation,, AGA 2026