A 34-year-old woman with a history of alcohol excess is admitted with abdominal swelling to the Acute Medical Unit. A diagnosis of ascites secondary to liver cirrhosis is made and paracentesis is performed. The serum creatinine on admission is 95 μmol/l. Ten days after admission urine output decreases significantly and blood tests reveal:
Albumin is given to correct suspected hypovolaemia.
What is the most appropriate further management?
Correct Answer C: This patient has developed hepatorenal syndrome.
Hepatorenal syndrome: management:
The management of hepatorenal syndrome (HRS) is notoriously difficult. The ideal treatment is liver transplantation but patients are often too unwell to have surgery and there is a shortage of donors Hepatorenal syndrome has been categorized into two types:
Management options:
A 29-year-old Russian man who has recently arrived into the country presents with fever and feeling generally unwell. His temperature is 38.2ºC and pulse 96/min. On examination a grey coating is seen surrounding the tonsils and there is extensive cervical lymphadenopathy.
What is the most likely diagnosis?
Correct Answer E: Diphtheria is caused by the Gram positive bacterium Corynebacterium diphtheriae.
Diphtheria toxin commonly causes a 'diphtheric membrane' on tonsils caused by necrotic mucosal cells.
Systemic distribution may produce necrosis of myocardial, neural and renal tissue.
Possible presentations:
A 29-year-old female is noted to have an elevated bilirubin during a viral illness. Gilbert's syndrome is suspected.
Which one of the following tests may confirm the diagnosis?
Correct Answer D:
Gilbert's syndrome: Gilbert's syndrome is an autosomal recessive* condition of defective bilirubin conjugation due to a deficiency of UDP glucuronyl transferase. The prevalence is approximately 1-2% in the general population.
Features:
Investigation and management:
*the exact mode of inheritance is still a matter of debate
What percentage of patients with Peutz-Jeghers syndrome will have died from a related cancer by the age of 60 years?
Correct Answer B:
Peutz-Jeghers syndrome: Peutz-Jeghers syndrome is an autosomal dominant condition characterized by numerous hamartomatous polyps in the gastrointestinal tract. It is also associated with pigmented freckles on the lips, face, palms and soles.
Around 50% of patients will have died from a gastrointestinal tract cancer by the age of 60 years.
Genetics:
Management:
A 45-year-old man with a history of alcoholic liver disease presents with abdominal distension. Examination reveals tense ascites which is drained.
What is the appropriate type of diuretic to help prevent re-accumulation of ascites?
Correct Answer A: Aldosterone antagonists such as spironolactone are used in high doses to help prevent the formation of ascites in patients with chronic liver disease. A loop diuretic may need to be added in patients who don't respond.
Spironolactone: Spironolactone is an aldosterone antagonist which acts act in the distal convoluted tubule.
Indications:
Adverse effects:
RALES:
Click to expand