{"id":36924,"date":"2026-06-03T20:04:01","date_gmt":"2026-06-03T14:34:01","guid":{"rendered":"https:\/\/atsixty.com\/?p=36924"},"modified":"2026-06-03T20:04:30","modified_gmt":"2026-06-03T14:34:30","slug":"biliary-diseases","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/","title":{"rendered":"Biliary 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 06 \u00b7 Biliary Diseases\n   Namespace: #git06\n   Palette: deep teal-green (GIT series standard)\n   Template: git05 \u2014 plain diff label, exp + Extra Points\n   ============================================================ *\/\n\n#git06 *,#git06 *::before,#git06 *::after{box-sizing:border-box;margin:0;padding:0}\n\n#git06{\n  --ter:#1A6B5A;\n  --ter-light:#2A8C77;\n  --ter-pale:#EBF6F3;\n  --ter-dark:#125048;\n  --correct:#2D6B47;\n  --correct-bg:#EAF6EF;\n  --correct-border:#3A9960;\n  --wrong:#B83232;\n  --wrong-bg:#FDF0F0;\n  --wrong-border:#E53935;\n  --ink:#1C2E2A;\n  --ink-mid:#3D5A54;\n  --ink-soft:#7A9A94;\n  --line:#D8E8E5;\n  --cream:#F5FAF9;\n  --warm:#FDFFFE;\n\n  font-family:'Source Serif 4',Georgia,serif;\n  font-size:16px;color:var(--ink);background:var(--cream);\n  line-height:1.7;padding:0 0 64px;\n}\n\n#git06 .mr-header{background:var(--ter);color:#FDFFFE;padding:34px 24px 28px;text-align:center}\n#git06 .mr-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#git06 .mr-title{font-family:'Playfair Display',serif;font-size:1.75rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#git06 .mr-title em{font-style:italic;font-weight:400;opacity:0.88}\n#git06 .mr-subtitle{font-size:0.82rem;opacity:0.7;margin-top:8px;font-style:italic}\n#git06 .mr-chips{display:flex;justify-content:center;gap:10px;margin-top:18px;flex-wrap:wrap}\n#git06 .mr-chip{background:rgba(255,255,255,0.13);border:1px solid rgba(255,255,255,0.22);border-radius:20px;padding:4px 13px;font-size:0.73rem}\n\n#git06 .mr-sentinel{height:1px}\n#git06 .mr-progress{position:fixed;top:0;left:0;right:0;z-index:9999;background:var(--warm);border-bottom:1px solid var(--line);box-shadow:0 2px 12px rgba(26,107,90,0.10);padding:9px 16px;display:none}\n#git06 .mr-progress.visible{display:block}\n#git06 .mr-prog-inner{max-width:720px;margin:0 auto;display:flex;align-items:center;justify-content:center}\n#git06 .mr-pips{display:flex;align-items:center;justify-content:center}\n#git06 .mr-pip-wrap{display:flex;align-items:center}\n#git06 .mr-pip-line{width:28px;height:2px;background:var(--line);transition:background 0.35s}\n#git06 .mr-pip-line.done{background:var(--ter)}\n#git06 .mr-pip{width:28px;height:28px;border-radius:50%;border:2px solid var(--line);background:var(--warm);display:flex;align-items:center;justify-content:center;font-size:0.63rem;font-weight:700;color:var(--ink-soft);transition:all 0.3s;flex-shrink:0}\n#git06 .mr-pip.correct{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#git06 .mr-pip.wrong{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n\n#git06 .mr-body{max-width:720px;margin:0 auto;padding:0 16px}\n#git06 .mr-case{background:var(--warm);border:1px solid var(--line);border-left:4px solid var(--ter);border-radius:10px;margin:28px 0;overflow:hidden;box-shadow:0 1px 6px rgba(26,107,90,0.06)}\n#git06 .mr-case-top{padding:16px 20px 14px;display:flex;gap:14px;align-items:flex-start}\n#git06 .mr-num{font-family:'Playfair Display',serif;font-size:2.2rem;font-weight:700;color:var(--ter);opacity:0.16;line-height:1;margin-top:-2px;flex-shrink:0}\n#git06 .mr-meta{flex:1}\n#git06 .mr-tag-row{display:flex;align-items:center;justify-content:space-between;margin-bottom:5px}\n#git06 .mr-tag{font-size:0.61rem;font-weight:700;letter-spacing:0.14em;text-transform:uppercase;color:var(--ter);opacity:0.8}\n#git06 .mr-diff{font-size:0.61rem;font-weight:700;letter-spacing:0.10em;text-transform:uppercase;color:var(--ink-soft)}\n#git06 .mr-stem{font-size:0.94rem;color:var(--ink);line-height:1.72}\n#git06 .mr-stem strong{font-weight:600}\n#git06 .mr-stem em{font-style:italic}\n#git06 .mr-rule{height:1px;background:var(--line);margin:0 20px}\n\n#git06 .mr-opts{padding:12px 20px 16px;display:flex;flex-direction:column;gap:8px}\n#git06 .mr-opt{display:flex;align-items:flex-start;gap:11px;padding:10px 14px;border:1.5px solid var(--line);border-radius:8px;cursor:pointer;background:var(--warm);transition:border-color 0.15s,background 0.15s;-webkit-tap-highlight-color:transparent}\n#git06 .mr-opt:hover{border-color:var(--ter);background:var(--ter-pale)}\n#git06 .mr-opt.locked{cursor:default}\n#git06 .mr-opt.locked:hover{border-color:var(--line);background:var(--warm)}\n#git06 .mr-opt.correct{border-color:var(--correct-border);background:var(--correct-bg);cursor:default}\n#git06 .mr-opt.correct:hover{border-color:var(--correct-border);background:var(--correct-bg)}\n#git06 .mr-opt.wrong{border-color:var(--wrong-border);background:var(--wrong-bg);cursor:default}\n#git06 .mr-opt.wrong:hover{border-color:var(--wrong-border);background:var(--wrong-bg)}\n#git06 .mr-opt.dimmed{opacity:0.35;cursor:default}\n#git06 .mr-opt.dimmed:hover{border-color:var(--line);background:var(--warm)}\n#git06 .mr-ltr{flex-shrink:0;width:20px;height:20px;border-radius:50%;border:1.5px solid var(--line);display:flex;align-items:center;justify-content:center;font-size:0.62rem;font-weight:700;color:var(--ink-soft);margin-top:2px;transition:all 0.15s}\n#git06 .mr-opt.correct .mr-ltr{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#git06 .mr-opt.wrong .mr-ltr{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#git06 .mr-opt-text{font-size:0.9rem;color:var(--ink-mid);line-height:1.58}\n#git06 .mr-opt.correct .mr-opt-text{color:var(--correct);font-weight:600}\n#git06 .mr-opt.wrong .mr-opt-text{color:var(--wrong)}\n\n#git06 .mr-exp{display:none;border-top:1px solid #b8ddd6;background:linear-gradient(180deg,#e8f5f2 0%,#f2faf8 100%);padding:13px 20px 15px}\n#git06 .mr-exp-lbl{font-size:0.61rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:var(--correct);margin-bottom:6px}\n#git06 .mr-exp-text{font-size:0.86rem;color:#1c4a3a;line-height:1.68}\n#git06 .mr-exp-text strong{font-weight:600}\n#git06 .mr-exp-text em{font-style:italic}\n#git06 .mr-exp-extra{margin-top:11px;padding-top:10px;border-top:1px dashed #9ACCC4;font-size:0.84rem;color:#1c4a3a;line-height:1.66}\n#git06 .mr-exp-extra-lbl{font-size:0.59rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:var(--ter);margin-bottom:4px;display:block}\n#git06 .mr-exp-extra strong{font-weight:600}\n#git06 .mr-exp-extra em{font-style:italic}\n\n#git06 .mr-submit-wrap{text-align:center;padding:28px 16px 8px}\n#git06 .mr-btn{background:var(--ter);color:#FDFFFE;border:none;border-radius:8px;padding:13px 44px;font-family:'Playfair Display',serif;font-size:1rem;font-weight:700;cursor:pointer;box-shadow:0 2px 8px rgba(26,107,90,0.30)}\n#git06 .mr-btn:hover{background:var(--ter-dark)}\n#git06 .mr-score{display:none;background:var(--warm);border:1px solid var(--line);border-top:4px solid var(--ter);border-radius:10px;margin:24px 0 0;box-shadow:0 2px 12px rgba(26,107,90,0.10);overflow:hidden}\n#git06 .mr-score-in{padding:28px 24px;text-align:center}\n#git06 .mr-score-ey{font-size:0.66rem;letter-spacing:0.14em;text-transform:uppercase;color:var(--ink-soft);margin-bottom:12px;font-weight:600}\n#git06 .mr-ring{width:98px;height:98px;border-radius:50%;background:conic-gradient(var(--ter) 0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 16px;position:relative}\n#git06 .mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#git06 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#git06 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--ter)}\n#git06 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#git06 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#git06 .mr-score-net{font-size:0.9rem;color:var(--ter);font-weight:600;margin-bottom:4px}\n#git06 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#git06 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#git06 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#git06 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#git06 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#git06 .mr-band-s{background:var(--ter-pale);color:var(--ter)}\n#git06 .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#git06 .mr-retry:hover{background:var(--ter);color:#FDFFFE}\n\n@media(max-width:480px){\n  #git06 .mr-title{font-size:1.4rem}\n  #git06 .mr-num{font-size:1.7rem}\n  #git06 .mr-stem{font-size:0.9rem}\n  #git06 .mr-opt-text{font-size:0.86rem}\n}\n<\/style>\n\n<div id=\"git06\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; GIT Series<\/div>\n    <div class=\"mr-title\">\n      Biliary 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=\"git06-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"git06-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"git06-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"git06-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"git06-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"git06-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"git06-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"git06-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=\"git06-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"git06-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"git06-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"git06-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"git06-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"git06-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n\n<script>\n\/* ============================================================\n   Morning Rounds \u00b7 GIT Quiz 06 \u00b7 Biliary Diseases\n   Namespace : git06\n   TOTAL     : 5 questions  |  MAX : 20  |  +4 \/ \u22121\n   Shuffle   : Fisher-Yates on options each build()\n   Correct   : matched by answer TEXT\n   Debrief   : q.exp = main text; q.extra = Extra Points para\n   ============================================================ *\/\n(function () {\n  'use strict';\n\n  var NS    = 'git06';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  \/* ================================================================\n     QUESTION BANK \u2014 Biliary Diseases\n     Topics: Cholelithiasis (gallstone types & risk factors),\n             Acute cholecystitis (Murphy's sign, management),\n             Choledocholithiasis & Charcot's triad,\n             Acute cholangitis & Reynold's pentad,\n             Primary Sclerosing Cholangitis (PSC)\n\n     Q1  CHOLELITHIASIS \u2014 STONE TYPES & RISK FACTORS (Easy)\n         Three types:\n           Cholesterol stones (80% in West, rising in India):\n             Risk factors: 5 Fs \u2014 Fat, Female, Fertile (>40 or\n             multiparity), Fair (Western\/North Indian), Forty.\n             Also: rapid weight loss, TPN, OCP, fibrates,\n             Crohn's (terminal ileum disease impairs bile salt\n             absorption), haemolytic anaemia (pigment overlap).\n             Composition: >50% cholesterol; yellow-white.\n             Radiolucent on X-ray (15% calcified = radio-opaque).\n             USS: gold standard for gallstones (>95% sensitivity).\n           Pigment stones \u2014 Black:\n             Chronic haemolysis (sickle cell, hereditary\n             spherocytosis, thalassaemia); cirrhosis; ileal\n             resection. Calcium bilirubinate. Radio-opaque.\n           Pigment stones \u2014 Brown:\n             Bacterial\/parasitic infection of bile ducts\n             (E. coli, Ascaris). Soft, earthy. Brown colour.\n             Common in Asia. Form in bile ducts, not gallbladder.\n         Answer: Cholesterol stones = 5 Fs; black pigment =\n                 haemolysis\/cirrhosis; brown pigment = infection;\n                 USS gold standard.\n\n     Q2  ACUTE CHOLECYSTITIS \u2014 MURPHY'S SIGN & MANAGEMENT (Easy)\n         Pathogenesis: stone impacts cystic duct \u2192 obstruction\n           \u2192 gallbladder distension \u2192 ischaemia \u2192 inflammation.\n           90% calculous; 10% acalculous (ICU patients, TPN,\n           major surgery, burns \u2014 poor prognosis).\n         Symptoms: RUQ pain (constant, unlike biliary colic\n           which is colicky and self-limiting), fever,\n           nausea\/vomiting, anorexia.\n         Murphy's sign: inspiratory arrest on deep palpation\n           of the RUQ (gallbladder descends onto examiner's\n           fingers during inspiration \u2192 pain \u2192 arrest).\n           Positive = acute cholecystitis.\n         Investigations: USS (thickened GB wall >4mm, pericholecystic\n           fluid, gallstones, sonographic Murphy's sign);\n           CT if USS equivocal.\n         Management: IV fluids, analgesia, IV antibiotics\n           (ceftriaxone \u00b1 metronidazole for anaerobes);\n           laparoscopic cholecystectomy \u2014 ideally early\n           (within 72 hrs; reduces hospital stay, complications,\n           conversion rate vs delayed interval cholecystectomy).\n         Complications: empyema, perforation, Mirizzi syndrome\n           (extrinsic compression of CHD by stone in Hartmann's\n           pouch), gallstone ileus (stone erodes into duodenum\n           \u2192 small bowel obstruction \u2192 Rigler's triad on X-ray).\n         Answer: Murphy's sign = inspiratory arrest RUQ;\n                 early laparoscopic cholecystectomy preferred;\n                 acalculous = ICU\/burns patients.\n\n     Q3  CHOLEDOCHOLITHIASIS \u2014 CHARCOT'S TRIAD (Medium)\n         Stone in common bile duct (CBD).\n         Presentation: obstructive jaundice + RUQ pain +\n           fever = Charcot's triad (indicates cholangitis\n           developing on top of CBD stone obstruction).\n         LFTs: conjugated (direct) hyperbilirubinaemia,\n           elevated ALP and GGT (cholestatic pattern),\n           mildly elevated transaminases.\n         Investigations: USS (CBD dilatation >6\u20138 mm),\n           MRCP (gold standard non-invasive \u2014 shows stone,\n           stricture, dilation), ERCP (therapeutic \u2014\n           sphincterotomy + stone extraction).\n         Management: ERCP + sphincterotomy + stone extraction;\n           followed by cholecystectomy to remove the source\n           (gallbladder).\n         Mirizzi syndrome: stone in Hartmann's pouch of\n           gallbladder externally compresses the CHD \u2192\n           obstructive jaundice without CBD stone;\n           cholecystectomy \u00b1 biliary repair.\n         Answer: Charcot's triad = jaundice + RUQ pain + fever;\n                 MRCP = gold standard diagnosis; ERCP = treatment.\n\n     Q4  ACUTE CHOLANGITIS \u2014 REYNOLD'S PENTAD & ERCP (Medium)\n         Ascending cholangitis: bacterial infection of bile ducts,\n           almost always on background of biliary obstruction\n           (CBD stone most common, stricture, post-ERCP).\n         Organisms: E. coli (#1), Klebsiella, Enterococcus,\n           Bacteroides, Clostridium.\n         Charcot's triad: RUQ pain + fever + jaundice.\n         Reynold's pentad: Charcot's triad + altered\n           consciousness (mental status change) + septic shock\n           = SEVERE cholangitis; high mortality; emergency ERCP.\n         Tokyo Guidelines severity grading:\n           Grade I (mild): responds to antibiotics.\n           Grade II (moderate): does not respond within 24 hr;\n             requires early biliary drainage.\n           Grade III (severe): organ dysfunction (Reynold's\n             pentad); emergency biliary drainage (ERCP preferred).\n         Management: IV antibiotics (pip-tazo or\n           ceftriaxone + metronidazole), aggressive IVF,\n           urgent ERCP + sphincterotomy + stone extraction\n           (or CBD stenting) in moderate-severe disease.\n         Answer: Reynold's pentad = Charcot's triad + confusion\n                 + shock; E. coli #1 organism; emergency ERCP\n                 for Grade III.\n\n     Q5  PRIMARY SCLEROSING CHOLANGITIS \u2014 PSC & UC LINK (Hard)\n         PSC: chronic fibro-inflammatory stricturing and\n           obliteration of intra- and extrahepatic bile ducts.\n         Aetiology: unknown; autoimmune features; HLA-B8\/DR3.\n         Association: 70\u201380% of PSC patients have IBD \u2014\n           almost exclusively UC (rarely Crohn's colitis).\n           Conversely, 5\u20138% of UC patients develop PSC.\n         Clinical: young-middle aged male, insidious onset,\n           fatigue, pruritus, jaundice, episodes of cholangitis.\n         Investigations:\n           MRCP: beaded appearance \u2014 multifocal strictures\n             alternating with normal\/dilated segments\n             (classic \"beads on a string\").\n           ERCP (now reserved for therapy, not diagnosis).\n           Liver biopsy: onion-skin fibrosis around bile ducts.\n           pANCA: positive in ~65\u201380% (non-specific).\n           IgG4: to exclude IgG4-related sclerosing cholangitis\n             (mimics PSC but responds to steroids).\n         Complications: dominant stricture, recurrent cholangitis,\n           cirrhosis, cholangiocarcinoma (10\u201315% lifetime risk \u2014\n           most feared complication), colorectal carcinoma\n           (via UC association).\n         Treatment: ursodeoxycholic acid (UDCA) \u2014 improves LFTs\n           but no proven survival benefit; ERCP \u00b1 stenting for\n           dominant strictures; liver transplantation = definitive.\n         No medical therapy alters disease progression.\n         Answer: Beads on a string (MRCP); UC association (70\u201380%);\n                 cholangiocarcinoma 10\u201315%; liver Tx = definitive.\n     ================================================================ *\/\n\n  var QS = [\n\n    \/* ---- Q1 : Cholelithiasis ---- *\/\n    {\n      id:      1,\n      diff:    'Easy',\n      tag:     'Biliary &mdash; Cholelithiasis',\n      stem:    'A <strong>42-year-old obese woman<\/strong> with two children presents with episodic right hypochondrial pain after fatty meals. Ultrasound confirms <strong>multiple gallstones<\/strong>. Her younger sister, who has <strong>hereditary spherocytosis<\/strong>, is also found to have gallstones on a routine scan despite being asymptomatic. A third patient \u2014 a <strong>62-year-old man admitted to the ICU<\/strong> for sepsis \u2014 develops acute right hypochondrial pain on day 10 with no gallstones on ultrasound. Which statement correctly identifies the stone type in each patient and explains the third patient\\'s condition?',\n      correct: 'First: cholesterol stones (obesity, female, multiparity \u2014 5 Fs risk factors); Second: black pigment stones (chronic haemolysis from hereditary spherocytosis increases unconjugated bilirubin in bile); Third: acalculous cholecystitis (gallbladder ischaemia and bile stasis in critically ill patients without stones)',\n      opts: [\n        'First: cholesterol stones (obesity, female, multiparity \u2014 5 Fs risk factors); Second: black pigment stones (chronic haemolysis from hereditary spherocytosis increases unconjugated bilirubin in bile); Third: acalculous cholecystitis (gallbladder ischaemia and bile stasis in critically ill patients without stones)',\n        'First: black pigment stones (obesity increases unconjugated bilirubin excretion); Second: cholesterol stones (haemolytic anaemia paradoxically causes cholesterol supersaturation of bile); Third: calculous cholecystitis with stones too small to detect on ultrasound',\n        'First: brown pigment stones (dietary fat triggers bacterial infection of the biliary system); Second: cholesterol stones (spherocytosis causes bile salt deficiency); Third: gangrenous cholecystitis caused by a large impacted stone at the cystic duct',\n        'First: cholesterol stones; Second: brown pigment stones (infection by E. coli in the bile ducts is triggered by haemolysis); Third: biliary dyskinesia causing functional obstruction without stones in a critically ill patient'\n      ],\n      exp: '<strong>Cholesterol stones<\/strong> (the commonest type in India and the West) form when bile becomes supersaturated with cholesterol relative to bile salts and lecithin. Risk factors: the classic <strong>5 Fs<\/strong> \u2014 Fat (obesity), Female, Fertile (multiparity or age &gt;40), Fair (North Indian \/ Western descent), Forty. Additional: rapid weight loss (mobilises cholesterol), OCP (reduces bile salt secretion), fibrates (increase cholesterol excretion), Crohn\\'s disease (terminal ileal disease reduces bile salt reabsorption \u2192 depletion of bile salt pool). Cholesterol stones are radiolucent on plain X-ray (only 15% calcify). <strong>Black pigment stones<\/strong> form in chronic haemolytic states (sickle cell disease, hereditary spherocytosis, thalassaemia) \u2014 excess unconjugated bilirubin is excreted into bile, precipitating as calcium bilirubinate. Also seen in cirrhosis. Radio-opaque. Form in the gallbladder. <strong>Brown pigment stones<\/strong>: infected bile (E. coli, Ascaris) \u2192 bacterial beta-glucuronidase deconjugates bilirubin \u2192 precipitation. Form in bile ducts; common in Asia. <strong>Acalculous cholecystitis<\/strong>: gallbladder inflammation without stones; occurs in ICU patients (major surgery, burns, TPN, mechanical ventilation) due to bile stasis + ischaemia. Carries higher mortality than calculous cholecystitis.',\n      extra: '<strong>Ultrasound<\/strong> is the gold standard for gallstone detection \u2014 sensitivity &gt;95%, specificity &gt;95%, non-invasive, no radiation, and readily available in district hospitals. It also assesses CBD diameter, liver parenchyma, and signs of cholecystitis (wall thickening, pericholecystic fluid, sonographic Murphy\\'s sign). <strong>Gallstone disease in India:<\/strong> cholesterol stones are increasingly common as dietary patterns westernise. In northern India, gallstones are particularly prevalent and gallbladder carcinoma \u2014 strongly associated with gallstones and Salmonella typhi chronic carriage \u2014 is the most common biliary malignancy and one of the commonest GI cancers in women in the Gangetic belt. This gallbladder carcinoma\u2013gallstone link is a high-yield CMS point.'\n    },\n\n    \/* ---- Q2 : Acute Cholecystitis ---- *\/\n    {\n      id:      2,\n      diff:    'Easy',\n      tag:     'Biliary &mdash; Acute Cholecystitis',\n      stem:    'A <strong>48-year-old woman<\/strong> presents with <strong>constant right hypochondrial pain for 18 hours<\/strong>, fever (38.6\u00b0C), nausea, and vomiting. She had similar but briefer episodes after meals. On examination, <strong>deep inspiration causes her to wince and stop breathing<\/strong> when the examiner\\'s hand is placed below the right costal margin. Ultrasound shows gallstones, gallbladder wall thickening of 6 mm, and pericholecystic fluid. WBC is 14,500\/mm\u00b3. Which sign is demonstrated, what is the preferred timing for surgery, and what is the single most dangerous complication of delayed management?',\n      correct: 'Murphy\\'s sign (inspiratory arrest on deep RUQ palpation); early laparoscopic cholecystectomy within 72 hours is preferred over interval cholecystectomy \u2014 equal safety, shorter hospital stay; gallbladder perforation with peritonitis is the most dangerous complication',\n      opts: [\n        'Murphy\\'s sign (inspiratory arrest on deep RUQ palpation); early laparoscopic cholecystectomy within 72 hours is preferred over interval cholecystectomy \u2014 equal safety, shorter hospital stay; gallbladder perforation with peritonitis is the most dangerous complication',\n        'Boas\\'s sign (referred pain to the right scapular tip); delayed cholecystectomy at 6 weeks is always preferred as it allows inflammation to resolve and reduces operative risk; the most dangerous complication is Mirizzi syndrome',\n        'Murphy\\'s sign; conservative management with antibiotics alone is sufficient for all cases of acute cholecystitis without requiring surgery; the most dangerous complication is biliary colic recurrence',\n        'Rovsing\\'s sign (pain in the RUQ on palpation of the LIF); interval cholecystectomy at 3 months is mandatory to allow complete fibrosis of the gallbladder before surgery; empyema is always fatal without open cholecystectomy'\n      ],\n      exp: '<strong>Murphy\\'s sign:<\/strong> the patient is asked to take a deep breath while the examiner\\'s fingers are placed below the right costal margin at the gallbladder point. The descending gallbladder contacts the examining fingers, causing pain that arrests inspiration \u2014 <em>inspiratory arrest<\/em>. A positive Murphy\\'s sign is highly specific for acute cholecystitis. <strong>Note:<\/strong> in elderly patients Murphy\\'s sign may be absent despite severe cholecystitis \u2014 always maintain a high index of suspicion. <strong>Timing of surgery:<\/strong> Multiple RCTs and meta-analyses confirm that <strong>early laparoscopic cholecystectomy within 72 hours<\/strong> of presentation is safe, reduces total hospital stay, reduces the risk of recurrent attacks during the waiting period, and has similar conversion-to-open rates compared to delayed (interval) cholecystectomy at 6 weeks. Early surgery is now the preferred approach in fit patients. <strong>Complications of delayed or inadequate management:<\/strong> empyema of gallbladder (pus-filled, requires cholecystostomy), gangrene, <strong>perforation with bile peritonitis<\/strong> (highest mortality), Mirizzi syndrome, and gallstone ileus.',\n      extra: '<strong>Mirizzi syndrome:<\/strong> a large stone impacted in Hartmann\\'s pouch (the infundibulum of the gallbladder) or the cystic duct exerts external pressure on the common hepatic duct (CHD), causing obstructive jaundice without a stone in the CBD. It is a surgical trap \u2014 imaging may suggest malignant obstruction. Requires careful surgical planning (cholecystectomy \u00b1 biliary reconstruction). <strong>Gallstone ileus:<\/strong> a large gallstone erodes through the gallbladder wall into the duodenum (cholecystoduodenal fistula) and impacts in the terminal ileum, causing small bowel obstruction. <strong>Rigler\\'s triad<\/strong> on plain X-ray: pneumobilia (air in biliary tree) + small bowel obstruction + ectopic calcified stone. This classic triad is reliably tested in both CMS and NEET-PG.'\n    },\n\n    \/* ---- Q3 : Choledocholithiasis ---- *\/\n    {\n      id:      3,\n      diff:    'Medium',\n      tag:     'Biliary &mdash; Choledocholithiasis',\n      stem:    'A <strong>55-year-old man<\/strong> known to have gallstones presents with <strong>jaundice, dark urine, pale stools, right hypochondrial pain, and fever of 38.8\u00b0C<\/strong> for two days. His bilirubin is predominantly conjugated, ALP is markedly elevated, and transaminases are mildly raised. Ultrasound shows CBD dilatation of 12 mm but no stone visualised in the duct. Which investigation is the <strong>gold standard for non-invasive diagnosis<\/strong>, what is the eponymous name for this clinical triad, and what is the definitive treatment?',\n      correct: 'MRCP is the gold standard non-invasive investigation for CBD stones and biliary pathology; Charcot\\'s triad (RUQ pain + jaundice + fever) indicates CBD stone with developing cholangitis; ERCP with sphincterotomy and stone extraction is the definitive treatment',\n      opts: [\n        'MRCP is the gold standard non-invasive investigation for CBD stones and biliary pathology; Charcot\\'s triad (RUQ pain + jaundice + fever) indicates CBD stone with developing cholangitis; ERCP with sphincterotomy and stone extraction is the definitive treatment',\n        'Ultrasound is the gold standard for CBD stones and has >95% sensitivity for detecting stones in the CBD; Courvoisier\\'s triad describes this combination; ERCP is contraindicated in the presence of fever and should only be performed after antibiotics for 2 weeks',\n        'CT abdomen with contrast is the gold standard for CBD stones as it detects both calcified and non-calcified stones equally; Charcot\\'s triad indicates gallbladder empyema; open cholecystectomy is the first treatment step before any biliary drainage',\n        'HIDA scan (hepatobiliary scintigraphy) is the gold standard to confirm CBD obstruction; Mirizzi syndrome is the diagnosis when all three features are present; cholecystostomy is the definitive treatment for CBD stones'\n      ],\n      exp: '<strong>Choledocholithiasis<\/strong> (CBD stone) is the primary cause of biliary obstruction leading to obstructive jaundice in a patient with known gallstones. The LFT pattern is <strong>cholestatic<\/strong>: predominantly conjugated (direct) hyperbilirubinaemia, markedly elevated ALP and GGT, mildly elevated transaminases. <strong>Charcot\\'s triad<\/strong> \u2014 RUQ pain + jaundice + fever \u2014 indicates that biliary obstruction from the CBD stone has been complicated by <strong>ascending cholangitis<\/strong> (bacterial infection of the obstructed biliary tree). <strong>Investigations:<\/strong> Ultrasound detects CBD dilatation reliably but visualises the actual stone in only 50\u201375% of cases (bowel gas obscures the distal CBD). <strong>MRCP<\/strong> (Magnetic Resonance Cholangiopancreatography) is the gold standard non-invasive investigation \u2014 sensitivity &gt;95% for CBD stones, shows the entire biliary tree, requires no contrast, no radiation, no instrumentation. <strong>ERCP<\/strong> is reserved for <em>therapeutic<\/em> purposes: sphincterotomy (cutting the sphincter of Oddi) + stone extraction with a Dormia basket or balloon. After ERCP clearance of the CBD, the gallbladder should be removed (laparoscopic cholecystectomy) to prevent recurrent stones.',\n      extra: '<strong>Intraoperative cholangiography (IOC)<\/strong>: performed during laparoscopic cholecystectomy by injecting contrast into the cystic duct \u2014 detects unsuspected CBD stones and maps biliary anatomy before clipping. Increasingly used to avoid retained stones. <strong>Endoscopic USS (EUS)<\/strong>: superior to MRCP for small CBD stones (&lt;5 mm) and is increasingly used when MRCP is equivocal. <strong>Mirizzi syndrome recap<\/strong> (from Q2): the stone is <em>outside<\/em> the CBD \u2014 in Hartmann\\'s pouch \u2014 but compresses the CHD externally. This causes obstructive jaundice that mimics CBD stone or malignancy. The distinction matters because ERCP cannot extract a stone that is not inside the duct \u2014 surgery is required.'\n    },\n\n    \/* ---- Q4 : Acute Cholangitis ---- *\/\n    {\n      id:      4,\n      diff:    'Medium',\n      tag:     'Biliary &mdash; Acute Cholangitis',\n      stem:    'A <strong>68-year-old man<\/strong> with known CBD stones is brought in with <strong>fever (39.5\u00b0C) with rigors, right hypochondrial pain, and jaundice<\/strong>. Over the next four hours he develops <strong>confusion and hypotension<\/strong> (BP 85\/50 mmHg). Blood cultures are drawn and IV antibiotics are started. His bilirubin is 8.2 mg\/dL and WBC is 22,000\/mm\u00b3. Ultrasound confirms CBD dilatation of 14 mm. What eponymous syndrome describes his complete clinical picture, what is the most common causative organism, and what is the next most critical intervention?',\n      correct: 'Reynold\\'s pentad (Charcot\\'s triad + altered consciousness + septic shock) indicating Grade III severe acute cholangitis; E. coli is the most common causative organism; emergency ERCP with biliary decompression is the most critical next intervention',\n      opts: [\n        'Reynold\\'s pentad (Charcot\\'s triad + altered consciousness + septic shock) indicating Grade III severe acute cholangitis; E. coli is the most common causative organism; emergency ERCP with biliary decompression is the most critical next intervention',\n        'Charcot\\'s triad with sepsis indicating Grade II moderate cholangitis; Klebsiella pneumoniae is the most common organism; emergency open common bile duct exploration is the preferred intervention over endoscopic drainage',\n        'Reynold\\'s pentad indicating acute liver failure complicating choledocholithiasis; Clostridium perfringens is the causative organism; percutaneous transhepatic cholangiography (PTC) is always preferred over ERCP in severe cholangitis',\n        'Cullen\\'s pentad (jaundice + fever + pain + confusion + shock) indicating haemorrhagic cholangitis; Bacteroides fragilis is the primary organism; surgical drainage is required before antibiotics can be effective'\n      ],\n      exp: '<strong>Acute cholangitis<\/strong> is a life-threatening infection of the bile ducts, almost always arising from biliary obstruction (CBD stone, stricture, post-ERCP). Bacteria ascend from the duodenum into the obstructed bile duct. <strong>Charcot\\'s triad<\/strong> (RUQ pain + fever + jaundice) is present in ~50\u201370% of cases. <strong>Reynold\\'s pentad<\/strong> = Charcot\\'s triad + <em>altered consciousness<\/em> + <em>septic shock<\/em> \u2014 indicates <strong>Grade III severe acute cholangitis<\/strong> per Tokyo Guidelines (2018), with multi-organ dysfunction and high mortality without emergency biliary drainage. <strong>Most common organism: <em>E. coli<\/em><\/strong>, followed by <em>Klebsiella<\/em>, <em>Enterococcus<\/em>, and anaerobes (<em>Bacteroides, Clostridium<\/em>). <strong>Management:<\/strong> IV antibiotics (piperacillin-tazobactam or ceftriaxone + metronidazole), aggressive IV fluids, and \u2014 crucially \u2014 <strong>emergency ERCP with biliary decompression<\/strong> (sphincterotomy + stone extraction or stent insertion). Antibiotics alone cannot sterilise an obstructed system; drainage is the definitive treatment. Percutaneous transhepatic biliary drainage (PTBD) is the alternative when ERCP fails or is unavailable.',\n      extra: '<strong>Tokyo Guidelines severity grading<\/strong> \u2014 a reliable exam framework:<br>Grade I (Mild): no organ dysfunction, responds to antibiotics and conservative management within 24 hours.<br>Grade II (Moderate): does not respond to initial treatment within 24 hours, or has two of: WBC &gt;12,000 or &lt;4,000, fever &gt;39\u00b0C, age &gt;75, bilirubin &gt;5 mg\/dL, hypoalbuminaemia. Requires early biliary drainage (within 24\u201348 hours).<br>Grade III (Severe): associated with organ dysfunction \u2014 cardiovascular (hypotension), neurological (confusion), respiratory (PaO\u2082\/FiO\u2082 &lt;300), renal (creatinine &gt;2), hepatic (INR &gt;1.5), haematological (platelets &lt;100,000). Requires emergency drainage and ICU support. <strong>Mortality of Grade III cholangitis without drainage: &gt;50%.<\/strong> This grading system is increasingly tested in NEET-PG.'\n    },\n\n    \/* ---- Q5 : Primary Sclerosing Cholangitis ---- *\/\n    {\n      id:      5,\n      diff:    'Hard',\n      tag:     'Biliary &mdash; Primary Sclerosing Cholangitis',\n      stem:    'A <strong>38-year-old man<\/strong> with a <strong>10-year history of ulcerative colitis<\/strong> presents with a <strong>6-month history of fatigue, intermittent jaundice, and pruritus<\/strong>. He has no gallstones. His ALP is 580 IU\/L, GGT is 420 IU\/L, and bilirubin is mildly elevated. MRCP shows <strong>multifocal stricturing and dilation of both intrahepatic and extrahepatic bile ducts<\/strong>. Liver biopsy shows periductal fibrosis. pANCA is positive. Which characteristic radiological description applies to his MRCP, what is his most feared long-term complication, and what is the only treatment that alters the natural history of his disease?',\n      correct: 'Beads on a string appearance (multifocal strictures alternating with normal or dilated segments); cholangiocarcinoma (10\u201315% lifetime risk, often difficult to detect early); liver transplantation is the only treatment that alters disease progression and improves survival',\n      opts: [\n        'Beads on a string appearance (multifocal strictures alternating with normal or dilated segments); cholangiocarcinoma (10\u201315% lifetime risk, often difficult to detect early); liver transplantation is the only treatment that alters disease progression and improves survival',\n        'Double duct sign (simultaneous CBD and pancreatic duct dilation); hepatocellular carcinoma is the most feared complication arising from cirrhosis; high-dose ursodeoxycholic acid (UDCA 28\u201330 mg\/kg\/day) is proven to halt disease progression',\n        'Bird-beak sign (smooth tapering of the CBD at the level of the sphincter of Oddi); cholangiocarcinoma risk is less than 1% and is not a significant concern; corticosteroids are the first-line treatment as PSC is an autoimmune condition',\n        'Beads on a string appearance; colorectal carcinoma from the underlying UC is the only malignant risk in PSC; ERCP with repeated balloon dilatation of all strictures is the definitive treatment for PSC'\n      ],\n      exp: '<strong>Primary Sclerosing Cholangitis (PSC)<\/strong> is a chronic progressive fibro-inflammatory disease causing <strong>multifocal stricturing<\/strong> of the intra- and extrahepatic bile ducts, leading ultimately to biliary cirrhosis. Predominantly affects young-to-middle-aged men. <strong>Association with IBD:<\/strong> 70\u201380% of PSC patients have UC (pancolitis is the most common pattern); only 5\u20138% of UC patients develop PSC. The association with Crohn\\'s colitis is much rarer. <strong>MRCP findings:<\/strong> the classical <strong>beads on a string<\/strong> appearance \u2014 alternating multifocal strictures and normal or mildly dilated segments throughout the biliary tree, resembling beads on a string. Liver biopsy shows <em>onion-skin fibrosis<\/em> (concentric periductal fibrosis) \u2014 pathognomonic but not always present on a single biopsy. <strong>Most feared complication:<\/strong> <strong>Cholangiocarcinoma<\/strong> \u2014 develops in 10\u201315% of PSC patients over a lifetime; arises from the chronically inflamed and dysplastic biliary epithelium; often presents insidiously with worsening jaundice or a dominant stricture on MRCP. Early detection is extremely difficult as serum CA 19-9 lacks sufficient sensitivity\/specificity in PSC.',\n      extra: '<strong>Treatment:<\/strong> UDCA improves liver biochemistry but multiple large RCTs (including the Mayo Clinic high-dose UDCA trial) have shown <em>no survival benefit<\/em> and at high doses (28\u201330 mg\/kg\/day) UDCA may actually <em>worsen<\/em> outcomes. It is no longer recommended as standard therapy for PSC. ERCP with balloon dilatation \u00b1 stenting is used for symptomatic <em>dominant strictures<\/em> (defined as CBD &lt;1.5 mm or hepatic duct &lt;1 mm). <strong>Liver transplantation<\/strong> is the only intervention that alters the natural history \u2014 5-year post-transplant survival is ~85%. However, PSC can recur in the transplanted liver. <strong>IgG4-related sclerosing cholangitis (IgG4-SC)<\/strong> is a crucial differential: it mimics PSC on imaging but responds dramatically to corticosteroids. Elevated serum IgG4 (&gt;2\u00d7 ULN) and tissue IgG4-positive plasma cells on biopsy confirm IgG4-SC. Always check IgG4 before diagnosing PSC \u2014 missing IgG4-SC means missing a treatable disease.'\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  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  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  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 ? '0' + q.id : String(q.id);\n      meta = document.createElement('div'); meta.className = 'mr-meta';\n\n      tagRow = document.createElement('div'); tagRow.className = 'mr-tag-row';\n      tg = document.createElement('div'); tg.className = 'mr-tag'; tg.innerHTML = q.tag;\n      dl = document.createElement('div'); dl.className = 'mr-diff'; dl.textContent = q.diff;\n      tagRow.appendChild(tg); tagRow.appendChild(dl);\n\n      st = document.createElement('div'); st.className = 'mr-stem'; st.innerHTML = q.stem;\n      meta.appendChild(tagRow); meta.appendChild(st);\n      top.appendChild(nd); top.appendChild(meta);\n      card.appendChild(top);\n\n      rule = document.createElement('div'); rule.className = 'mr-rule';\n      card.appendChild(rule);\n\n      od = document.createElement('div'); od.className = 'mr-opts';\n      for (j = 0; j < opts.length; j++) {\n        oe = document.createElement('div'); oe.className = 'mr-opt';\n        oe.id = NS + '-o' + q.id + '-' + j;\n        oe.setAttribute('role', 'button'); oe.setAttribute('tabindex', '0');\n        ls = document.createElement('span'); ls.className = 'mr-ltr'; ls.textContent = LTRS[j];\n        ts = document.createElement('span'); ts.className = 'mr-opt-text'; ts.innerHTML = opts[j];\n        oe.appendChild(ls); oe.appendChild(ts); od.appendChild(oe);\n        (function (qid, oi) {\n          oe.addEventListener('click', function () { pick(qid, oi); });\n        }(q.id, j));\n      }\n      card.appendChild(od);\n\n      ed  = document.createElement('div'); ed.className = 'mr-exp'; ed.id = NS + '-exp' + q.id;\n      lb  = document.createElement('div'); lb.className = 'mr-exp-lbl'; lb.textContent = 'Debrief';\n      tx  = document.createElement('div'); tx.className = 'mr-exp-text'; tx.innerHTML = q.exp;\n      ed.appendChild(lb); ed.appendChild(tx);\n\n      if (q.extra) {\n        ep  = document.createElement('div'); ep.className = 'mr-exp-extra';\n        epl = document.createElement('span'); epl.className = 'mr-exp-extra-lbl'; epl.textContent = 'Extra Points';\n        ept = document.createElement('div'); ept.innerHTML = q.extra;\n        ep.appendChild(epl); ep.appendChild(ept);\n        ed.appendChild(ep);\n      }\n\n      card.appendChild(ed);\n      cont.appendChild(card);\n    }\n  }\n\n  function pick(qid, oi) {\n    var q, opts, i, el, ok;\n    if (answers[qid] !== undefined || done) return;\n    q = null;\n    for (i = 0; i < QS.length; i++) { if (QS[i].id === qid) { q = QS[i]; break; } }\n    if (!q) return;\n    opts = shuffled[qid];\n    ok   = (opts[oi] === q.correct);\n    answers[qid] = ok ? 'c' : 'w';\n    answered++;\n    for (i = 0; i < opts.length; i++) {\n      el = byId(NS + '-o' + qid + '-' + i);\n      if (!el) continue;\n      el.className = opts[i] === q.correct ? 'mr-opt correct locked'\n                   : i === oi              ? 'mr-opt wrong locked'\n                                           : 'mr-opt dimmed locked';\n    }\n    var ex = byId(NS + '-exp' + qid); if (ex) ex.style.display = 'block';\n    var pp = byId(NS + '-pip' + qid); if (pp) pp.className = 'mr-pip ' + (ok ? 'correct' : 'wrong');\n    if (qid > 1) { var pl = gid('pl' + qid); if (pl) pl.className = 'mr-pip-line done'; }\n  }\n\n  function showScore() {\n    var c, w, s, net, pct, disp, vlist, vi, sc;\n    if (done) return;\n    done = true;\n    c   = countVal('c'); w = countVal('w'); s = TOTAL - answered;\n    net  = c * 4 - w;\n    pct  = Math.max(0, Math.round((net \/ MAX) * 100));\n    disp = Math.min(100, Math.max(0, pct));\n    var rg = gid('ring');\n    if (rg) rg.style.background = 'conic-gradient(#1A6B5A ' + disp + '%, #D8E8E5 0%)';\n    var pe = gid('pct'); if (pe) pe.textContent = pct + '%';\n    var ne = gid('net'); if (ne) ne.textContent = 'Net Score: ' + net + ' \/ ' + MAX;\n    vlist = [\n      [5, 'Flawless. The biliary tree holds no mysteries for you. GIT series complete.'],\n      [4, 'Strong finish \\u2014 one eponym or complication worth a final read.'],\n      [3, 'Solid base \\u2014 the Extra Points carry the clinical edge for exam day.'],\n      [2, 'Halfway there \\u2014 Reynold\\'s pentad and PSC are the places to focus.'],\n      [0, 'Biliary diseases reward pattern recognition. The debrief panels have everything \\u2014 one more pass will make it click.']\n    ];\n    var ve = gid('verdict');\n    if (ve) {\n      ve.textContent = vlist[4][1];\n      for (vi = 0; vi < vlist.length; vi++) {\n        if (c >= vlist[vi][0]) { ve.textContent = vlist[vi][1]; break; }\n      }\n    }\n    var cc = gid('ct-c'); if (cc) cc.textContent = '\\u2705 ' + c + ' Correct';\n    var cw = gid('ct-w'); if (cw) cw.textContent = '\\u274C ' + w + ' Wrong';\n    var cs = gid('ct-s'); if (cs) cs.textContent = '\\u23ED ' + s + ' Skipped';\n    sc = gid('score');\n    if (sc) { sc.style.display = 'block'; sc.scrollIntoView({ behavior: 'smooth', block: 'center' }); }\n  }\n\n  function initObserver() {\n    var sn = gid('sentinel'), bar = gid('progress');\n    if (!sn || !bar || !window.IntersectionObserver) return;\n    new IntersectionObserver(function (en) {\n      bar.className = en[0].isIntersecting ? 'mr-progress' : 'mr-progress visible';\n    }, { threshold: 0 }).observe(sn);\n  }\n\n  function init() {\n    var sb = gid('submit'), rb = gid('retry');\n    if (!sb || !rb) return;\n    sb.addEventListener('click', showScore);\n    rb.addEventListener('click', function () { build(); window.scrollTo(0, 0); });\n    initObserver();\n    build();\n  }\n\n  function tryInit(n) {\n    if (document.getElementById('git06-cases')) {\n      init();\n    } else if (n < 40) {\n      setTimeout(function () { tryInit(n + 1); }, 50);\n    }\n  }\n\n  tryInit(0);\n\n}());\n<\/script>\n\n\n","protected":false},"excerpt":{"rendered":"<p>Morning Rounds &middot; GIT Series Biliary DiseasesGastroenterology Five high-yield clinical cases &middot; +4 \/ &minus;1 scoring &middot; NEET-PG and UPSC CMS 5 Cases +4 \/ &minus;1 scoring Options reshuffled Submit for Debrief Round Complete 0% net Your Debrief &#8635; New Round<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"neve_meta_sidebar":"","neve_meta_container":"","neve_meta_enable_content_width":"","neve_meta_content_width":0,"neve_meta_title_alignment":"","neve_meta_author_avatar":"","neve_post_elements_order":"","neve_meta_disable_header":"","neve_meta_disable_footer":"","neve_meta_disable_title":"","footnotes":""},"categories":[18,76,74,24],"tags":[],"class_list":["post-36924","post","type-post","status-publish","format-standard","hentry","category-cms","category-git","category-morning-rounds","category-neet-pg"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.7 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Biliary Diseases - atsixty<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Biliary Diseases - atsixty\" \/>\n<meta property=\"og:description\" content=\"Morning Rounds &middot; GIT Series Biliary DiseasesGastroenterology Five high-yield clinical cases &middot; +4 \/ &minus;1 scoring &middot; NEET-PG and UPSC CMS 5 Cases +4 \/ &minus;1 scoring Options reshuffled Submit for Debrief Round Complete 0% net Your Debrief &#8635; New Round\" \/>\n<meta property=\"og:url\" content=\"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/\" \/>\n<meta property=\"og:site_name\" content=\"atsixty\" \/>\n<meta property=\"article:published_time\" content=\"2026-06-03T14:34:01+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2026-06-03T14:34:30+00:00\" \/>\n<meta name=\"author\" content=\"Avi\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"Avi\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/\"},\"author\":{\"name\":\"Avi\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\"},\"headline\":\"Biliary Diseases\",\"datePublished\":\"2026-06-03T14:34:01+00:00\",\"dateModified\":\"2026-06-03T14:34:30+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/\"},\"wordCount\":37,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\"},\"articleSection\":[\"CMS\",\"GIT\",\"Morning Rounds\",\"NEET PG\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/\",\"url\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/\",\"name\":\"Biliary Diseases - atsixty\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/#website\"},\"datePublished\":\"2026-06-03T14:34:01+00:00\",\"dateModified\":\"2026-06-03T14:34:30+00:00\",\"breadcrumb\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/cms\\\/biliary-diseases\\\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\\\/\\\/atsixty.com\\\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Biliary Diseases\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/#website\",\"url\":\"https:\\\/\\\/atsixty.com\\\/\",\"name\":\"At Sixty\",\"description\":\"The Option Taken\",\"publisher\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\\\/\\\/atsixty.com\\\/?s={search_term_string}\"},\"query-input\":{\"@type\":\"PropertyValueSpecification\",\"valueRequired\":true,\"valueName\":\"search_term_string\"}}],\"inLanguage\":\"en-US\"},{\"@type\":[\"Person\",\"Organization\"],\"@id\":\"https:\\\/\\\/atsixty.com\\\/#\\\/schema\\\/person\\\/cf65e7ac7d8226d95c0bdf1036f7951d\",\"name\":\"Avi\",\"image\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\",\"url\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\",\"contentUrl\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\",\"width\":200,\"height\":200,\"caption\":\"Avi\"},\"logo\":{\"@id\":\"https:\\\/\\\/atsixty.com\\\/wp-content\\\/uploads\\\/2025\\\/08\\\/logo-agency.png\"},\"sameAs\":[\"https:\\\/\\\/atsixty.com\"],\"url\":\"https:\\\/\\\/atsixty.com\\\/index.php\\\/author\\\/avinaux\\\/\"}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Biliary Diseases - atsixty","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/","og_locale":"en_US","og_type":"article","og_title":"Biliary Diseases - atsixty","og_description":"Morning Rounds &middot; GIT Series Biliary DiseasesGastroenterology Five high-yield clinical cases &middot; +4 \/ &minus;1 scoring &middot; NEET-PG and UPSC CMS 5 Cases +4 \/ &minus;1 scoring Options reshuffled Submit for Debrief Round Complete 0% net Your Debrief &#8635; New Round","og_url":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/","og_site_name":"atsixty","article_published_time":"2026-06-03T14:34:01+00:00","article_modified_time":"2026-06-03T14:34:30+00:00","author":"Avi","twitter_card":"summary_large_image","twitter_misc":{"Written by":"Avi","Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"Article","@id":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/#article","isPartOf":{"@id":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/"},"author":{"name":"Avi","@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d"},"headline":"Biliary Diseases","datePublished":"2026-06-03T14:34:01+00:00","dateModified":"2026-06-03T14:34:30+00:00","mainEntityOfPage":{"@id":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/"},"wordCount":37,"commentCount":0,"publisher":{"@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d"},"articleSection":["CMS","GIT","Morning Rounds","NEET PG"],"inLanguage":"en-US","potentialAction":[{"@type":"CommentAction","name":"Comment","target":["https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/#respond"]}]},{"@type":"WebPage","@id":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/","url":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/","name":"Biliary Diseases - atsixty","isPartOf":{"@id":"https:\/\/atsixty.com\/#website"},"datePublished":"2026-06-03T14:34:01+00:00","dateModified":"2026-06-03T14:34:30+00:00","breadcrumb":{"@id":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/atsixty.com\/index.php\/cms\/biliary-diseases\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/atsixty.com\/"},{"@type":"ListItem","position":2,"name":"Biliary Diseases"}]},{"@type":"WebSite","@id":"https:\/\/atsixty.com\/#website","url":"https:\/\/atsixty.com\/","name":"At Sixty","description":"The Option Taken","publisher":{"@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/atsixty.com\/?s={search_term_string}"},"query-input":{"@type":"PropertyValueSpecification","valueRequired":true,"valueName":"search_term_string"}}],"inLanguage":"en-US"},{"@type":["Person","Organization"],"@id":"https:\/\/atsixty.com\/#\/schema\/person\/cf65e7ac7d8226d95c0bdf1036f7951d","name":"Avi","image":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png","url":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png","contentUrl":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png","width":200,"height":200,"caption":"Avi"},"logo":{"@id":"https:\/\/atsixty.com\/wp-content\/uploads\/2025\/08\/logo-agency.png"},"sameAs":["https:\/\/atsixty.com"],"url":"https:\/\/atsixty.com\/index.php\/author\/avinaux\/"}]}},"_links":{"self":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts\/36924","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/comments?post=36924"}],"version-history":[{"count":1,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts\/36924\/revisions"}],"predecessor-version":[{"id":36925,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/posts\/36924\/revisions\/36925"}],"wp:attachment":[{"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/media?parent=36924"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/categories?post=36924"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/atsixty.com\/index.php\/wp-json\/wp\/v2\/tags?post=36924"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}