{"id":36916,"date":"2026-06-03T19:49:52","date_gmt":"2026-06-03T14:19:52","guid":{"rendered":"https:\/\/atsixty.com\/?p=36916"},"modified":"2026-06-03T19:51:26","modified_gmt":"2026-06-03T14:21:26","slug":"intestinal-diseases","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/cms\/intestinal-diseases\/","title":{"rendered":"Intestinal Diseases"},"content":{"rendered":"\n\n\n<link href=\"https:\/\/fonts.googleapis.com\/css2?family=Playfair+Display:ital,wght@0,400;0,600;0,700;1,400;1,600&#038;family=Source+Serif+4:ital,wght@0,300;0,400;0,600;1,400&#038;display=swap\" rel=\"stylesheet\">\n<style>\n\/* ============================================================\n   Morning Rounds \u00b7 GIT Quiz 02 \u00b7 Intestinal Diseases\n   Namespace: #git02\n   Palette: deep teal-green (same as GIT series)\n   Changes from git01:\n     - Difficulty: text label only (Easy \/ Medium \/ Hard),\n       no dot pips \u2014 removed per feedback\n     - Debrief: two-block layout 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.mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#git02 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#git02 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--ter)}\n#git02 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#git02 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#git02 .mr-score-net{font-size:0.9rem;color:var(--ter);font-weight:600;margin-bottom:4px}\n#git02 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#git02 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#git02 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#git02 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#git02 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#git02 .mr-band-s{background:var(--ter-pale);color:var(--ter)}\n#git02 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--ter);color:var(--ter);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#git02 .mr-retry:hover{background:var(--ter);color:#FDFFFE}\n\n@media(max-width:480px){\n  #git02 .mr-title{font-size:1.4rem}\n  #git02 .mr-num{font-size:1.7rem}\n  #git02 .mr-stem{font-size:0.9rem}\n  #git02 .mr-opt-text{font-size:0.86rem}\n}\n<\/style>\n\n<div id=\"git02\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; GIT Series<\/div>\n    <div class=\"mr-title\">\n      Intestinal Diseases<br><em>Gastroenterology<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five high-yield clinical cases &middot; +4 \/ &minus;1 scoring &middot; NEET-PG and UPSC CMS<\/div>\n    <div class=\"mr-chips\">\n      <span class=\"mr-chip\">5 Cases<\/span>\n      <span class=\"mr-chip\">+4 \/ &minus;1 scoring<\/span>\n      <span class=\"mr-chip\">Options reshuffled<\/span>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-sentinel\" id=\"git02-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"git02-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"git02-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"git02-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"git02-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"git02-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"git02-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"git02-pct\">0%<\/span>\n            <span class=\"mr-ring-sub\">net<\/span>\n          <\/div>\n        <\/div>\n        <div class=\"mr-score-title\">Your Debrief<\/div>\n        <div class=\"mr-score-net\" id=\"git02-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"git02-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"git02-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"git02-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"git02-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"git02-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n\n<script>\n\/* ============================================================\n   Morning Rounds \u00b7 GIT Quiz 02 \u00b7 Intestinal Diseases\n   Namespace : git02\n   TOTAL     : 5 questions\n   MAX score : 20 (5 \u00d7 4)\n   Scoring   : correct +4, wrong \u22121, skipped 0\n   Shuffle   : Fisher-Yates on options each build()\n   Correct   : matched by answer TEXT (survives shuffle)\n   Debrief   : q.exp = main text; q.extra = Extra Points para\n   Difficulty: q.diff string ('Easy' \/ 'Medium' \/ 'Hard')\n                rendered as plain text label \u2014 no dot pips\n   ============================================================ *\/\n(function () {\n  'use strict';\n\n  var NS    = 'git02';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  \/* ================================================================\n     QUESTION BANK \u2014 Intestinal Diseases\n     Topics: IBS, IBD (Crohn's vs UC), Intestinal TB,\n             Coeliac Disease, Acute Diarrhoea (infective)\n     NEET-PG \/ UPSC CMS level. Clinical vignette format.\n     diff: 'Easy' | 'Medium' | 'Hard'\n\n     Q1  IRRITABLE BOWEL SYNDROME \u2014 ROME IV CRITERIA (Easy)\n         Functional disorder; no structural or biochemical cause.\n         Rome IV: recurrent abdominal pain \u22651 day\/week for \u22653\n         months, associated with \u22652 of: related to defaecation,\n         change in stool frequency, change in stool form.\n         Subtypes: IBS-C, IBS-D, IBS-M (mixed), IBS-U.\n         Alarm features (RED FLAGS) that exclude IBS:\n         age >50 at onset, rectal bleeding, nocturnal symptoms\n         waking patient, unintentional weight loss, anaemia,\n         family history of CRC\/IBD\/coeliac, fever.\n         Management: reassurance + dietary (low-FODMAP diet),\n         antispasmodics (mebeverine), antidiarrhoeals\n         (loperamide for IBS-D), laxatives for IBS-C.\n         Answer: Rome IV criteria (pain + defaecation\/frequency\/\n                 form change); RED FLAGS exclude diagnosis.\n\n     Q2  CROHN'S DISEASE vs ULCERATIVE COLITIS \u2014 KEY DIFFERENCES (Medium)\n         Crohn's (CD): any part of GIT mouth to anus; transmural;\n         skip lesions; cobblestone mucosa; non-caseating\n         granulomas; fistulae, strictures, abscesses;\n         terminal ileum most common; perianal disease;\n         smoking worsens CD (protective in UC).\n         UC: continuous, starts at rectum, extends proximally;\n         mucosal only; no skip lesions; pseudo-polyps;\n         crypt abscesses (histology); loss of haustrations\n         on barium enema (lead pipe colon); backwash ileitis\n         possible; colorectal cancer risk (after 8-10 yr);\n         smoking is protective in UC.\n         Common: bloody diarrhoea (UC > CD), extraintestinal\n         manifestations (uveitis, arthritis, PSC, EN, PG).\n         PSC strongly associated with UC.\n         Toxic megacolon: UC (more common) or CD.\n         Answer: CD \u2014 transmural, skip lesions, granulomas,\n         fistulae; UC \u2014 mucosal, continuous from rectum,\n         crypt abscesses, CRC risk.\n\n     Q3  INTESTINAL TUBERCULOSIS \u2014 vs CROHN'S DISEASE (Medium)\n         India-specific, very high yield for CMS and NEET-PG.\n         Site: ileocaecal region (most common).\n         Types: ulcerative (commoner in India), hypertrophic,\n                ulcerohypertrophic.\n         Pathology: caseating granulomas (vs non-caseating in CD).\n         Barium studies: Stierlin's sign \u2014 rapid emptying of\n         barium from the diseased segment (irritability).\n         Fleischner sign: thickening and rigidity of ileocaecal\n         region.\n         Distinguishing from CD: caseating granulomas, AFB on\n         culture, IGRA\/Mantoux, response to ATT.\n         Surgery: right hemicolectomy for hypertrophic\/obstructive.\n         Answer: Ileocaecal region; caseating granulomas;\n                 Stierlin's sign; must be excluded before treating\n                 as CD (anti-TNF agents can exacerbate TB).\n\n     Q4  COELIAC DISEASE \u2014 PATHOLOGY & DIAGNOSIS (Medium)\n         Autoimmune enteropathy triggered by gluten\n         (gliadin fraction) in genetically susceptible individuals\n         (HLA-DQ2 in ~95%, DQ8 in ~5%).\n         Pathology (Marsh classification):\n           Marsh I: increased intraepithelial lymphocytes (IEL)\n           Marsh II: + crypt hyperplasia\n           Marsh III: + villous atrophy (a\/b\/c subtotal\u2192total)\n         Classic: diarrhoea, steatorrhoea, weight loss, bloating.\n         Atypical: iron-deficiency anaemia (most common\n         presentation in adults in India), short stature,\n         infertility, osteoporosis, dermatitis herpetiformis.\n         Serology: anti-tissue transglutaminase IgA (tTG-IgA)\n         \u2014 screening test of choice; check total IgA to exclude\n         IgA deficiency (which gives false negative tTG-IgA).\n         Gold standard: duodenal biopsy (D2) on gluten-containing\n         diet \u2192 villous atrophy + crypt hyperplasia + IEL.\n         Treatment: strict lifelong gluten-free diet.\n         Answer: HLA-DQ2\/DQ8; tTG-IgA screening; duodenal\n                 biopsy gold standard; villous atrophy + IEL.\n\n     Q5  ACUTE INFECTIVE DIARRHOEA \u2014 SECRETARY vs INVASIVE (Hard)\n         India: cholera (V. cholerae El Tor), ETEC, rotavirus\n         (children), Salmonella, Shigella, Campylobacter,\n         E. coli O157:H7 (HUS), Entamoeba.\n         Secretory (non-invasive): watery, no blood, no pus,\n         no fever; stool WBC absent; mechanism: enterotoxin\n         (CT of cholera \u2014 Gs \u2192 \u2191cAMP \u2192 Cl\u207b secretion).\n         Invasive (inflammatory): blood\/mucus in stool, fever,\n         tenesmus; stool WBC present; organisms: Shigella,\n         Campylobacter, Entamoeba, EIEC, Salmonella typhi.\n         Cholera: rice-water stools; ORS is life-saving;\n         tetracycline\/doxycycline shortens duration.\n         Shigella: most common cause of bacillary dysentery\n         in India; antibiotic treatment reduces severity and\n         carriage (ciprofloxacin or azithromycin).\n         HUS: E. coli O157:H7 \u2192 Shiga toxin \u2192 microangiopathic\n         haemolytic anaemia + thrombocytopaenia + AKI.\n         Antibiotics CONTRAINDICATED in E. coli O157 (\u2191HUS risk).\n         Answer: Secretory = watery, no WBC, cAMP mechanism;\n                 Invasive = bloody, WBC positive, fever; HUS\n                 from O157 \u2014 antibiotics contraindicated.\n     ================================================================ *\/\n\n  var QS = [\n\n    \/* ---- Q1 : IBS ---- *\/\n    {\n      id:      1,\n      diff:    'Easy',\n      tag:     'Intestine &mdash; IBS',\n      stem:    'A <strong>32-year-old woman<\/strong> presents with a <strong>2-year history of crampy lower abdominal pain<\/strong> that is relieved by defaecation. She alternates between loose stools and constipation, with no blood in stools. She has no nocturnal symptoms, no weight loss, and no fever. Full blood count, CRP, and colonoscopy are normal. Which criterion set correctly diagnoses her condition, and which single feature, if present, would most strongly argue against this diagnosis?',\n      correct: 'Rome IV criteria (recurrent abdominal pain \u22651 day\/week for \u22653 months, related to defaecation or change in stool frequency\/form); rectal bleeding would be a red flag arguing against IBS',\n      opts: [\n        'Rome IV criteria (recurrent abdominal pain \u22651 day\/week for \u22653 months, related to defaecation or change in stool frequency\/form); rectal bleeding would be a red flag arguing against IBS',\n        'Manning criteria (pain relieved by defaecation, looser stools with pain onset, visible mucus per rectum); elevated CRP would be a red flag arguing against IBS',\n        'Rome IV criteria (abdominal pain every day for \u22656 months, always related to eating); unintentional weight gain would be the key red flag against IBS',\n        'Kruis criteria (abdominal pain + bloating + altered bowel habit for \u22652 years); normal colonoscopy is necessary but not sufficient to diagnose IBS by these criteria'\n      ],\n      exp: '<strong>IBS<\/strong> is diagnosed by the <strong>Rome IV criteria<\/strong>: recurrent abdominal pain on average \u22651 day per week for the last 3 months, associated with \u22652 of: (1) related to defaecation, (2) associated with a change in frequency of stool, (3) associated with a change in form (appearance) of stool. Onset must be \u22656 months before diagnosis. <strong>Subtypes:<\/strong> IBS-C (constipation predominant), IBS-D (diarrhoea predominant), IBS-M (mixed), IBS-U (unclassified). <strong>Management:<\/strong> reassurance and explanation; dietary modification (low-FODMAP diet reduces symptoms in ~70%); antispasmodics (mebeverine, hyoscine) for pain; loperamide for IBS-D; osmotic laxatives for IBS-C.',\n      extra: '<strong>Red flags that exclude IBS and mandate investigation:<\/strong> age &gt;50 at symptom onset, rectal bleeding or melaena, nocturnal symptoms waking the patient, unintentional weight loss, iron-deficiency anaemia, elevated inflammatory markers (CRP\/ESR), family history of colorectal cancer, IBD, or coeliac disease, fever, or abdominal mass. In clinical practice and CMS exams, the key skill is recognising when to stop reassuring and start investigating \u2014 IBS is a diagnosis of exclusion.'\n    },\n\n    \/* ---- Q2 : Crohn's vs UC ---- *\/\n    {\n      id:      2,\n      diff:    'Medium',\n      tag:     'IBD &mdash; Crohn\\'s vs Ulcerative Colitis',\n      stem:    'A <strong>28-year-old man<\/strong> presents with <strong>bloody diarrhoea, crampy abdominal pain, and 5 kg weight loss<\/strong> over three months. Colonoscopy reveals <strong>skip lesions with cobblestone mucosa<\/strong>, and biopsies show <strong>transmural inflammation with non-caseating granulomas<\/strong>. A perianal fistula is present. Which statement best contrasts this condition with the other major form of inflammatory bowel disease?',\n      correct: 'Crohn\\'s disease: transmural, any site from mouth to anus, skip lesions, non-caseating granulomas, fistulae; UC: mucosal only, continuous from rectum, crypt abscesses, higher colorectal cancer risk; smoking worsens Crohn\\'s but is protective in UC',\n      opts: [\n        'Crohn\\'s disease: transmural, any site from mouth to anus, skip lesions, non-caseating granulomas, fistulae; UC: mucosal only, continuous from rectum, crypt abscesses, higher colorectal cancer risk; smoking worsens Crohn\\'s but is protective in UC',\n        'Crohn\\'s disease: mucosal inflammation confined to the colon, continuous from rectum, crypt abscesses on histology; UC: transmural, skip lesions, may affect small bowel, fistulae common; smoking has identical effects in both',\n        'Crohn\\'s disease: associated with primary sclerosing cholangitis (PSC) more strongly than UC; UC: associated with perianal disease and fistulae; both show non-caseating granulomas on biopsy',\n        'Crohn\\'s disease and UC are both confined to the large bowel; the distinction is that Crohn\\'s starts proximally and UC starts at the rectum; malignant potential is equal in both'\n      ],\n      exp: '<strong>Crohn\\'s disease (CD):<\/strong> affects any part of the GIT from mouth to anus; <em>transmural<\/em> inflammation; <em>skip lesions<\/em>; cobblestone mucosa; <strong>non-caseating granulomas<\/strong> on histology; complications include fistulae, strictures, abscesses, and perianal disease; terminal ileum is the most common site. <strong>Ulcerative colitis (UC):<\/strong> confined to the colon and rectum; <em>mucosal<\/em> inflammation only; <em>continuous<\/em> disease starting at the rectum and extending proximally; <strong>crypt abscesses<\/strong> on histology; pseudo-polyps; loss of haustrations on barium enema (lead-pipe colon); colorectal cancer risk rises significantly after 8&ndash;10 years of pancolitis. <strong>Extraintestinal manifestations<\/strong> (both): uveitis\/episcleritis, seronegative arthritis, erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis (PSC \u2014 more strongly linked to UC), ankylosing spondylitis.',\n      extra: '<strong>Smoking:<\/strong> one of the most testable facts in IBD \u2014 smoking <em>worsens<\/em> Crohn\\'s disease (dose-dependent) but is paradoxically <em>protective<\/em> in UC (nicotine patches are even used therapeutically in UC flares). <strong>PSC association:<\/strong> 70\u201380% of PSC patients have UC; PSC raises CRC risk independently. <strong>Toxic megacolon<\/strong> (colonic dilatation &gt;6 cm with systemic toxicity) is more common in UC but can occur in CD; plain abdominal X-ray is the investigation of choice \u2014 colonoscopy and barium enema are <em>contraindicated<\/em> in suspected toxic megacolon due to perforation risk. This X-ray point is high yield for CMS.'\n    },\n\n    \/* ---- Q3 : Intestinal TB ---- *\/\n    {\n      id:      3,\n      diff:    'Medium',\n      tag:     'Intestine &mdash; Intestinal Tuberculosis',\n      stem:    'A <strong>35-year-old man<\/strong> from rural Jharkhand presents with <strong>right iliac fossa pain, weight loss, low-grade evening fever, and alternating diarrhoea and constipation<\/strong>. Colonoscopy shows <strong>ulceration and thickening at the ileocaecal region<\/strong> with a patulous ileocaecal valve. Biopsy reveals <strong>caseating granulomas<\/strong>. The characteristic barium study finding and the critical reason to confirm this diagnosis before initiating any biological therapy are:',\n      correct: 'Stierlin\\'s sign (rapid emptying of barium from the diseased segment due to irritability); anti-TNF agents used in Crohn\\'s disease can reactivate latent TB and cause disseminated disease',\n      opts: [\n        'Stierlin\\'s sign (rapid emptying of barium from the diseased segment due to irritability); anti-TNF agents used in Crohn\\'s disease can reactivate latent TB and cause disseminated disease',\n        'String sign of Kantor (narrow barium column through a strictured terminal ileum); steroids used in Crohn\\'s disease are safe in intestinal TB and do not worsen infection',\n        'Fleischner sign (thickening of ileocaecal folds seen on barium enema); anti-TNF agents have no interaction with TB and the diagnosis does not affect treatment choice',\n        'Rose thorn ulcers (deep fissuring ulcers on barium follow-through); the patulous ileocaecal valve distinguishes Crohn\\'s disease from intestinal TB and makes TB unlikely'\n      ],\n      exp: '<strong>Intestinal TB<\/strong> is the most common abdominal TB manifestation and predominantly affects the <strong>ileocaecal region<\/strong> (75&ndash;90% of cases), because of the abundance of lymphoid tissue (Peyer\\'s patches) and the physiological stasis at the ileocaecal valve. <strong>Types:<\/strong> ulcerative (commonest in India \u2014 transverse ulcers, in contrast to the longitudinal ulcers of CD), hypertrophic, and ulcerohypertrophic. <strong>Histology:<\/strong> <em>caseating granulomas<\/em> \u2014 the key differentiator from Crohn\\'s (non-caseating). The ileocaecal valve is <em>patulous (gaping)<\/em> in TB, unlike Crohn\\'s where it is narrowed. <strong>Barium studies:<\/strong> <em>Stierlin\\'s sign<\/em> \u2014 the barium-filled caecum and terminal ileum empty rapidly due to inflammatory irritability of the diseased bowel; <em>Fleischner sign<\/em> \u2014 thickening and retraction of the ileocaecal folds.',\n      extra: '<strong>Why distinguish from Crohn\\'s before starting biological therapy?<\/strong> Anti-TNF agents (infliximab, adalimumab) used for Crohn\\'s disease can reactivate latent <em>Mycobacterium tuberculosis<\/em>, leading to disseminated or miliary TB \u2014 a potentially fatal complication. All patients being considered for anti-TNF therapy must be screened with IGRA (interferon-gamma release assay) or Mantoux, and intestinal TB must be actively excluded. In India, where TB prevalence is high, this clinical distinction is not academic \u2014 it is a patient-safety imperative and a reliable CMS\/NEET-PG exam point.'\n    },\n\n    \/* ---- Q4 : Coeliac Disease ---- *\/\n    {\n      id:      4,\n      diff:    'Medium',\n      tag:     'Intestine &mdash; Coeliac Disease',\n      stem:    'A <strong>28-year-old woman<\/strong> presents with <strong>fatigue, iron-deficiency anaemia refractory to oral iron, and mild bloating<\/strong>. She has no overt diarrhoea. Her anti-tissue transglutaminase IgA (tTG-IgA) is strongly positive. Duodenal biopsy shows <strong>villous atrophy, crypt hyperplasia, and increased intraepithelial lymphocytes<\/strong>. The HLA association and the single most important management step are:',\n      correct: 'HLA-DQ2 (~95% of cases) or HLA-DQ8 (~5%); strict lifelong gluten-free diet \u2014 the only effective treatment, which leads to mucosal healing and resolution of anaemia',\n      opts: [\n        'HLA-DQ2 (~95% of cases) or HLA-DQ8 (~5%); strict lifelong gluten-free diet \u2014 the only effective treatment, which leads to mucosal healing and resolution of anaemia',\n        'HLA-B27 (>90% of cases); gluten restriction for 6 months followed by gluten reintroduction to assess tolerance is the standard management',\n        'HLA-DR3\/DQ2 in ~50% and no HLA association in the remaining 50%; corticosteroids are first-line treatment for villous atrophy before dietary changes',\n        'HLA-A1\/B8\/DR3 haplotype exclusively; elemental diet (amino acid-based formula) is the first-line treatment, with gluten reintroduction after mucosal healing confirmed on repeat biopsy'\n      ],\n      exp: '<strong>Coeliac disease<\/strong> is an autoimmune enteropathy triggered by <strong>gluten<\/strong> (specifically the gliadin fraction of wheat, rye, and barley) in genetically predisposed individuals. <strong>HLA:<\/strong> HLA-DQ2 is present in ~95% of patients; HLA-DQ8 in most of the remainder \u2014 necessary but not sufficient for disease. <strong>Marsh classification<\/strong> of duodenal biopsy: Type I \u2014 increased intraepithelial lymphocytes (IEL, &gt;25 per 100 enterocytes) only; Type II \u2014 + crypt hyperplasia; Type III (a\/b\/c) \u2014 + partial to total villous atrophy. <strong>Serology:<\/strong> anti-tTG IgA is the preferred screening test; always check total IgA simultaneously \u2014 IgA deficiency (1 in 500 in the general population, much more common in coeliac patients) gives a false-negative tTG-IgA, in which case anti-tTG IgG or anti-DGP IgG should be used. <strong>Gold standard:<\/strong> duodenal biopsy (from D2) while on a gluten-containing diet. <strong>Treatment:<\/strong> strict lifelong gluten-free diet.',\n      extra: '<strong>Presentations to remember for exams:<\/strong> Iron-deficiency anaemia refractory to oral iron is the most common presentation of coeliac disease in Indian adults (as in this case) \u2014 diarrhoea may be absent entirely. Other atypical presentations: short stature in children, infertility, recurrent miscarriage, osteoporosis, peripheral neuropathy, and <strong>dermatitis herpetiformis<\/strong> (intensely pruritic, symmetrical vesicular rash over elbows, knees, buttocks \u2014 pathognomonic cutaneous manifestation of coeliac disease; tTG-IgA positive; gluten-free diet is the treatment). <strong>Complications of untreated coeliac:<\/strong> refractory coeliac disease, enteropathy-associated T-cell lymphoma (EATL \u2014 a serious and exam-favourite complication), small bowel adenocarcinoma.'\n    },\n\n    \/* ---- Q5 : Acute Infective Diarrhoea ---- *\/\n    {\n      id:      5,\n      diff:    'Hard',\n      tag:     'Intestine &mdash; Acute Infective Diarrhoea',\n      stem:    'A <strong>6-year-old child<\/strong> develops <strong>bloody diarrhoea with fever and abdominal cramps<\/strong> five days after a picnic. Three days later she develops <strong>oliguria, pallor, and petechiae<\/strong>. Investigations show microangiopathic haemolytic anaemia, thrombocytopenia, and rising creatinine. A classmate who attended the same picnic has profuse <strong>watery diarrhoea without blood or fever<\/strong>. The causative organism in the first child, the triad of her complication, and the critical treatment caveat are:',\n      correct: 'E. coli O157:H7 (Shiga toxin-producing); haemolytic uraemic syndrome (HUS) = microangiopathic haemolytic anaemia + thrombocytopaenia + acute kidney injury; antibiotics are contraindicated as they increase Shiga toxin release and worsen HUS',\n      opts: [\n        'E. coli O157:H7 (Shiga toxin-producing); haemolytic uraemic syndrome (HUS) = microangiopathic haemolytic anaemia + thrombocytopaenia + acute kidney injury; antibiotics are contraindicated as they increase Shiga toxin release and worsen HUS',\n        'Shigella dysenteriae type 1; haemolytic uraemic syndrome (HUS) = haemolytic anaemia + thrombocytopaenia + AKI; antibiotics (ciprofloxacin) are first-line treatment and reduce HUS risk',\n        'Campylobacter jejuni; Guillain-Barr\u00e9 syndrome = ascending paralysis post-diarrhoeal illness; IVIg is first-line treatment and antibiotics do not affect GBS outcome',\n        'Entamoeba histolytica; amoebic liver abscess triad = fever + right hypochondrial pain + leukocytosis; metronidazole is the drug of choice and is safe in children'\n      ],\n      exp: '<strong>E. coli O157:H7<\/strong> (STEC \u2014 Shiga toxin-producing E. coli) causes haemorrhagic colitis: bloody diarrhoea, abdominal cramps, low or no fever. The <strong>Shiga toxin<\/strong> (verotoxin) damages renal endothelium and leads to <strong>haemolytic uraemic syndrome (HUS)<\/strong> in 5&ndash;10% of infected children. <strong>HUS triad:<\/strong> microangiopathic haemolytic anaemia (MAHA) + thrombocytopaenia + acute kidney injury. <strong>Critical treatment rule:<\/strong> <em>antibiotics are contraindicated<\/em> in STEC infection \u2014 they cause bacterial cell lysis, massively increasing Shiga toxin release into the circulation, worsening HUS. Management is supportive: IV fluids, dialysis if needed, blood transfusion. <strong>The classmate<\/strong> with watery, non-bloody, afebrile diarrhoea most likely has a secretory diarrhoea (ETEC, rotavirus, or cholera-like) \u2014 the mechanism is enterotoxin-mediated (e.g., cholera toxin activates Gs \u2192 \u2191cAMP \u2192 CFTR-mediated Cl\u207b secretion), with no mucosal invasion and no stool WBCs.',\n      extra: '<strong>Distinguishing secretory from invasive diarrhoea<\/strong> is a fundamental CMS clinical skill. Secretory: large-volume watery stools, no blood, no fever, no stool WBCs \u2014 treat with ORS (oral rehydration salts) first and foremost; antibiotics only for cholera (doxycycline) to shorten duration and reduce transmission. Invasive (dysenteric): blood\/mucus, fever, tenesmus, stool WBCs positive \u2014 organisms include <em>Shigella<\/em> (commonest bacillary dysentery in India; treat with ciprofloxacin or azithromycin), <em>Campylobacter<\/em>, <em>Entamoeba histolytica<\/em> (amoebic dysentery \u2014 metronidazole + luminal agent), and EIEC. <strong>Post-infectious complications to remember:<\/strong> Campylobacter \u2192 Guillain-Barr\u00e9 syndrome; Yersinia\/Salmonella \u2192 reactive arthritis; STEC O157 \u2192 HUS. These are high-yield one-liners for both NEET-PG and CMS.'\n    }\n\n  ];\n  \/* ================================================================\n     END OF CONTENT \u2014 engine logic below, do not edit\n     ================================================================ *\/\n\n  var answers  = {};\n  var answered = 0;\n  var shuffled = {};\n  var done     = false;\n\n  function byId(id) { return document.getElementById(id); }\n  function gid(sfx) { return byId(NS + '-' + sfx); }\n\n  \/* Fisher-Yates shuffle *\/\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, t;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      t = a[i]; a[i] = a[j]; a[j] = t;\n    }\n    return a;\n  }\n\n  function countVal(val) {\n    var k, n = 0;\n    for (k in answers) {\n      if (answers.hasOwnProperty(k) && answers[k] === val) n++;\n    }\n    return n;\n  }\n\n  \/* Build progress pips *\/\n  function buildPips() {\n    var cont = gid('pips'), i, q, wl, wp, line, pip;\n    if (!cont) return;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wl = document.createElement('div'); wl.className = 'mr-pip-wrap';\n        line = document.createElement('div'); line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wl.appendChild(line); cont.appendChild(wl);\n      }\n      wp  = document.createElement('div'); wp.className = 'mr-pip-wrap';\n      pip = document.createElement('div'); pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wp.appendChild(pip); cont.appendChild(wp);\n    }\n  }\n\n  \/* Build all question cards *\/\n  function build() {\n    var cont, i, q, opts, card, top, nd, meta, tagRow, tg, dl,\n        st, rule, od, ed, lb, tx, ep, epl, ept, j, oe, ls, ts;\n    cont = gid('cases');\n    if (!cont) return;\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    if (gid('score')) gid('score').style.display = 'none';\n    buildPips();\n    for (i = 0; i < QS.length; i++) {\n      q    = QS[i];\n      opts = shuffleArr(q.opts);\n      shuffled[q.id] = opts;\n\n      card = document.createElement('div'); card.className = 'mr-case';\n      top  = document.createElement('div'); top.className  = 'mr-case-top';\n      nd   = document.createElement('div'); nd.className   = 'mr-num';\n      nd.textContent = q.id < 10 ? 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Intestinal diseases are firmly in your grasp.'],\n      [4, 'Strong round \\u2014 one mechanism worth revisiting before exam day.'],\n      [3, 'Good base \\u2014 the Extra Points sections have the edge you need.'],\n      [2, 'Halfway there \\u2014 IBD and infective diarrhoea reward a focused re-read.'],\n      [0, 'Intestinal diseases are high-yield. 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