A 46-year-old man with chronic liver disease secondary to alcohol misuse was seen in the outpatient clinic.



Which of the following factors is most important for variceal development? 

A 40-year-old man with cirrhosis and known oesophageal varies presented to hospital with haematemesis. He was encephalopathic. 



Initial observations: 

blood pressure                       87/55 mmHg



pulse                                    120 beats/minute 

temperature                          36.1°C



oxygen saturations                 91% on room air 

respiratory rate                      21 breaths/minute 



Investigations:

haemoglobin on venous gas        902 g/L (130–180) 

platelet count                            15 × 109/L (150–400) 

ABO blood group                        A negative 



Which of the following statements about the resuscitation of patients with variceal haemorrhage is most accurate? 

A variceal screening gastroscopy was performed on a 42-year-old woman with recently diagnosed chronic liver disease secondary to non-alcoholic fatty liver disease (NAFLD). She had not had a variceal bleed before. She was intolerant of propranolol and had Child–Pugh grade C cirrhosis. Her endoscopy revealed grade II/medium oesophageal varices with no visible ‘red signs.’



Which of the following is the best treatment plan? 

A 52-year-old man with advanced alcoholic liver cirrhosis was admitted with a fall. He was not known to have chronic renal impairment. He was taking spironolactone, which was stopped on admission, and he had moderate volume ascites.

 

Investigations on admission:

sodium                       124 mmol/L (137–144) 

potassium                   5.8 mmol/L (3.5–4.9) 

urea                           10.4 mmol/L (2.5–7.0) 

creatinine                   180 μmol/L (60–110) 

urine dipstick              protein: trace  

USS renal tract           normal sized kidneys with no hydronephrosis 

septic screen              negative 



After 48 hours of uid resuscitation, including human albumin solution, his bloods results were as follows: 



sodium                     127 mmol/L (137–144)

potassium                 5.7 mmol/L (3.5–4.9)

urea                         7.2 mmol/L (2.5–7.0)

creatinine                 150 μmol/L (60–110) 



What is the next best option for management?                  



   

A 61-year-old woman was diagnosed with hepatorenal syndrome.



Which of the following ndings best describes the earliest manifestation of hepatorenal syndrome (HRS)?