Welcome to Grey Matters, where we unpack how medical management is rarely black or white.

And we go on deep dives along the way. I'm Dr. Jason Freed and I'm a hematologist at Beth Israel

Deaconess Medical Center. And I'm Dr. Ali trainer and I'm a pulmonary

and critical care fellow at the Harvard Combined Program at MGH

and Beth Israel Deaconess.

So this week we have a special guest joining us. Dr. Elliot Tapper, who's a hepetologist at University of Michigan.

He posted a thread on Twitter a while back about a patient that he took care of.

And Ali, you and I both independently read it and thought, okay, we have to have him on to talk through this case

with us.

Yeah, exactly.

I'll let Dr. Tapper introduce the case. A woman in her 50 who has alcohol related cirrhosis and the main reason why she presented for care was because of a citis and she also had a padrothorax.

So when we first met her, our goal was to try to control her volume overload with diuretics. The problem was that as we tried to increase

those the dosage of those medications we started to run into trouble with kidney injury or hypercalemia, hyponatremia.

She was diuretic resistance. So she was in a given week getting both a perecenthesis and a thoracentesis. And for her, the

main complicating factor was that she had an elevated INR, something like 1.9 to 2.1,

and we bounce around. Yikes, weekly parensesis and thoracentesis.

Also, Abbatic hydrothorox has always sort of baffled me,

that the fluid is somehow getting from your abdomen to your chest cavity.

Like, you have a diaphragm in the way.

Right?

I was always confused by this too, but what happens is that you have these teeny tiny defects

in your diaphragm and when you breathe,

...