{"id":37056,"date":"2026-06-17T04:02:10","date_gmt":"2026-06-16T22:32:10","guid":{"rendered":"https:\/\/atsixty.com\/?p=37056"},"modified":"2026-06-17T22:49:57","modified_gmt":"2026-06-17T17:19:57","slug":"lower-gi-surgery","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/clinical\/surgery\/lower-gi-surgery\/","title":{"rendered":"Lower GI Surgery"},"content":{"rendered":"\n\n\n<meta charset=\"UTF-8\">\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\">\n<title>Morning Rounds \u00b7 Lower GI Surgery<\/title>\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#surg02 *,#surg02 *::before,#surg02 *::after{box-sizing:border-box;margin:0;padding:0}\n#surg02{\n  --surg:#2C5F8A;\n  --surg-light:#3A78A8;\n  --surg-pale:#EBF2F8;\n  --surg-dark:#1E4464;\n  --correct:#2D6B47;--correct-bg:#EAF6EF;--correct-border:#3A9960;\n  --wrong:#B83232;--wrong-bg:#FDF0F0;--wrong-border:#E53935;\n  --ink:#1A2A38;--ink-mid:#3A5A6A;--ink-soft:#7A98AD;\n  --line:#D6E5EE;--cream:#F4F8FB;--warm:#FAFCFE;\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#surg02 .mr-header{background:var(--surg);color:#EEF5FA;padding:34px 24px 28px;text-align:center}\n#surg02 .mr-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#surg02 .mr-title{font-family:'Playfair Display',serif;font-size:1.75rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#surg02 .mr-title em{font-style:italic;font-weight:400;opacity:0.88}\n#surg02 .mr-subtitle{font-size:0.82rem;opacity:0.7;margin-top:8px;font-style:italic}\n#surg02 .mr-chips{display:flex;justify-content:center;gap:10px;margin-top:18px;flex-wrap:wrap}\n#surg02 .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#surg02 .mr-sentinel{height:1px}\n#surg02 .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(26,42,56,0.08);padding:9px 16px;display:none}\n#surg02 .mr-progress.visible{display:block}\n#surg02 .mr-prog-inner{max-width:720px;margin:0 auto;display:flex;align-items:center;justify-content:center}\n#surg02 .mr-pips{display:flex;align-items:center;justify-content:center}\n#surg02 .mr-pip-wrap{display:flex;align-items:center}\n#surg02 .mr-pip-line{width:28px;height:2px;background:var(--line);transition:background 0.35s}\n#surg02 .mr-pip-line.done{background:var(--surg)}\n#surg02 .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#surg02 .mr-pip.correct{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#surg02 .mr-pip.wrong{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#surg02 .mr-body{max-width:720px;margin:0 auto;padding:0 16px}\n#surg02 .mr-case{background:var(--warm);border:1px solid var(--line);border-left:4px solid var(--surg);border-radius:10px;margin:28px 0;overflow:hidden;box-shadow:0 1px 6px rgba(26,42,56,0.05)}\n#surg02 .mr-case-top{padding:16px 20px 14px;display:flex;gap:14px;align-items:flex-start}\n#surg02 .mr-num{font-family:'Playfair Display',serif;font-size:2.2rem;font-weight:700;color:var(--surg);opacity:0.16;line-height:1;margin-top:-2px;flex-shrink:0}\n#surg02 .mr-meta{flex:1}\n#surg02 .mr-tag{font-size:0.61rem;font-weight:700;letter-spacing:0.14em;text-transform:uppercase;color:var(--surg);opacity:0.75;margin-bottom:5px}\n#surg02 .mr-stem{font-size:0.94rem;color:var(--ink);line-height:1.72}\n#surg02 .mr-stem strong{font-weight:600}\n#surg02 .mr-stem em{font-style:italic}\n#surg02 .mr-rule{height:1px;background:var(--line);margin:0 20px}\n#surg02 .mr-opts{padding:12px 20px 16px;display:flex;flex-direction:column;gap:8px}\n#surg02 .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#surg02 .mr-opt:hover{border-color:var(--surg);background:var(--surg-pale)}\n#surg02 .mr-opt.locked{cursor:default}\n#surg02 .mr-opt.locked:hover{border-color:var(--line);background:var(--warm)}\n#surg02 .mr-opt.correct{border-color:var(--correct-border);background:var(--correct-bg);cursor:default}\n#surg02 .mr-opt.correct:hover{border-color:var(--correct-border);background:var(--correct-bg)}\n#surg02 .mr-opt.wrong{border-color:var(--wrong-border);background:var(--wrong-bg);cursor:default}\n#surg02 .mr-opt.wrong:hover{border-color:var(--wrong-border);background:var(--wrong-bg)}\n#surg02 .mr-opt.dimmed{opacity:0.35;cursor:default}\n#surg02 .mr-opt.dimmed:hover{border-color:var(--line);background:var(--warm)}\n#surg02 .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#surg02 .mr-opt.correct .mr-ltr{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#surg02 .mr-opt.wrong .mr-ltr{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#surg02 .mr-opt-text{font-size:0.9rem;color:var(--ink-mid);line-height:1.58}\n#surg02 .mr-opt.correct .mr-opt-text{color:var(--correct);font-weight:600}\n#surg02 .mr-opt.wrong .mr-opt-text{color:var(--wrong)}\n#surg02 .mr-exp{display:none;border-top:1px solid #b8d4e4;background:linear-gradient(180deg,#e4f0f7 0%,#f0f7fb 100%);padding:13px 20px 15px}\n#surg02 .mr-exp-lbl{font-size:0.61rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:#1a5070;margin-bottom:6px}\n#surg02 .mr-exp-text{font-size:0.86rem;color:#12324A;line-height:1.68}\n#surg02 .mr-exp-text strong{font-weight:600}\n#surg02 .mr-exp-text em{font-style:italic}\n#surg02 .mr-img-wrap{margin-top:14px;background:var(--warm);border:1px solid var(--line);border-radius:8px;padding:14px;text-align:center}\n#surg02 .mr-img-wrap figcaption{font-size:0.73rem;color:var(--ink-soft);font-style:italic;margin-top:8px;line-height:1.4}\n#surg02 .mr-submit-wrap{text-align:center;padding:28px 16px 8px}\n#surg02 .mr-btn{background:var(--surg);color:#EEF5FA;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(44,95,138,0.28)}\n#surg02 .mr-btn:hover{background:var(--surg-dark)}\n#surg02 .mr-score{display:none;background:var(--warm);border:1px solid var(--line);border-top:4px solid var(--surg);border-radius:10px;margin:24px 0 0;box-shadow:0 2px 12px rgba(26,42,56,0.08);overflow:hidden}\n#surg02 .mr-score-in{padding:28px 24px;text-align:center}\n#surg02 .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#surg02 .mr-ring{width:98px;height:98px;border-radius:50%;background:conic-gradient(var(--surg) 0%,var(--line) 0%);display:flex;align-items:center;justify-content:center;margin:0 auto 16px;position:relative}\n#surg02 .mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#surg02 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#surg02 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--surg)}\n#surg02 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#surg02 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#surg02 .mr-score-net{font-size:0.9rem;color:var(--surg);font-weight:600;margin-bottom:4px}\n#surg02 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#surg02 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#surg02 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#surg02 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#surg02 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#surg02 .mr-band-s{background:var(--surg-pale);color:var(--surg)}\n#surg02 .mr-retry{display:block;margin:18px auto 4px;background:transparent;border:2px solid var(--surg);color:var(--surg);border-radius:8px;padding:9px 28px;font-family:'Playfair Display',serif;font-size:0.92rem;font-weight:700;cursor:pointer}\n#surg02 .mr-retry:hover{background:var(--surg);color:#EEF5FA}\n@media(max-width:480px){#surg02 .mr-title{font-size:1.4rem}#surg02 .mr-num{font-size:1.7rem}#surg02 .mr-stem{font-size:0.9rem}#surg02 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- SVG Q2: Crohn's vs UC \u2014 key differentiators -->\n<div id=\"surg02-img2\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 230\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"230\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Crohn's Disease vs Ulcerative Colitis \u2014 Surgical Differentiators<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"150\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"165\" y=\"24\" width=\"185\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"355\" y=\"24\" width=\"195\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"85\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <text x=\"257\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Crohn's Disease<\/text>\n      <text x=\"452\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Ulcerative Colitis<\/text>\n      <!-- Distribution -->\n      <rect x=\"10\" y=\"48\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\" y=\"65\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Distribution<\/text>\n      <rect x=\"165\" y=\"48\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"257\" y=\"58\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Any part mouth to anus;<\/text>\n      <text x=\"257\" y=\"69\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">skip lesions<\/text>\n      <rect x=\"355\" y=\"48\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"452\" y=\"58\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Rectum \u2192 proximal, continuous;<\/text>\n      <text x=\"452\" y=\"69\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">always involves rectum<\/text>\n      <!-- Wall -->\n      <rect x=\"10\" y=\"76\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\" y=\"93\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Wall involvement<\/text>\n      <rect x=\"165\" y=\"76\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"257\" y=\"93\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Transmural (full thickness)<\/text>\n      <rect x=\"355\" y=\"76\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"452\" y=\"93\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Mucosal + submucosal only<\/text>\n      <!-- Appearance -->\n      <rect x=\"10\" y=\"104\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\" y=\"121\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Endoscopy<\/text>\n      <rect x=\"165\" y=\"104\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"257\" y=\"114\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Cobblestone mucosa, deep<\/text>\n      <text x=\"257\" y=\"125\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">fissuring ulcers, skip areas<\/text>\n      <rect x=\"355\" y=\"104\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"452\" y=\"114\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Continuous erythema, friability,<\/text>\n      <text x=\"452\" y=\"125\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">pseudopolyps, loss of haustra<\/text>\n      <!-- Histology -->\n      <rect x=\"10\" y=\"132\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\" y=\"149\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Histology hallmark<\/text>\n      <rect x=\"165\" y=\"132\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"257\" y=\"149\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Non-caseating granulomas<\/text>\n      <rect x=\"355\" y=\"132\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"452\" y=\"149\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Crypt abscesses; no granulomas<\/text>\n      <!-- Complications -->\n      <rect x=\"10\" y=\"160\" width=\"150\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\" y=\"177\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Unique complications<\/text>\n      <rect x=\"165\" y=\"160\" width=\"185\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"257\" y=\"170\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Fistulae, strictures, abscess,<\/text>\n      <text x=\"257\" y=\"181\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">perianal disease, SB malabsorption<\/text>\n      <rect x=\"355\" y=\"160\" width=\"195\" height=\"26\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"452\" y=\"170\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Toxic megacolon, high Ca colon<\/text>\n      <text x=\"452\" y=\"181\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">risk, PSC association<\/text>\n      <!-- Surgery -->\n      <rect x=\"10\" y=\"188\" width=\"150\" height=\"36\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"85\" y=\"205\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Surgery<\/text>\n      <rect x=\"165\" y=\"188\" width=\"185\" height=\"36\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"257\" y=\"199\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">NOT curative<\/text>\n      <text x=\"257\" y=\"210\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Resection + primary anastomosis;<\/text>\n      <text x=\"257\" y=\"221\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">conserve bowel; disease recurs<\/text>\n      <rect x=\"355\" y=\"188\" width=\"195\" height=\"36\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"452\" y=\"199\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">CURATIVE<\/text>\n      <text x=\"452\" y=\"210\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Proctocolectomy + IPAA (pouch)<\/text>\n      <text x=\"452\" y=\"221\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">or permanent ileostomy<\/text>\n    <\/svg>\n    <figcaption>\n      The single most tested differentiator: <strong>surgery is curative in UC, never curative in Crohn's<\/strong>. Transmural involvement in Crohn's explains fistulae and abscesses; mucosal-only UC explains why toxic megacolon is its major acute complication. PSC (primary sclerosing cholangitis) is strongly linked to UC, not Crohn's.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q4: Sigmoid Volvulus \u2014 X-ray signs -->\n<div id=\"surg02-img4\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 175\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"175\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Colonic Volvulus \u2014 Radiology &amp; Management<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"140\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"155\" y=\"24\" width=\"190\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"350\" y=\"24\" width=\"200\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"80\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Feature<\/text>\n      <text x=\"250\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Sigmoid Volvulus (MC)<\/text>\n      <text x=\"450\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Caecal Volvulus<\/text>\n      <!-- X-ray sign -->\n      <rect x=\"10\" y=\"48\" width=\"140\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"80\" y=\"66\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">X-ray sign<\/text>\n      <rect x=\"155\" y=\"48\" width=\"190\" height=\"28\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"250\" y=\"59\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Coffee-bean \/ omega sign<\/text>\n      <text x=\"250\" y=\"70\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Points toward RUQ<\/text>\n      <rect x=\"350\" y=\"48\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"450\" y=\"59\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Coffee-bean in RLQ\/centre<\/text>\n      <text x=\"450\" y=\"70\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Points toward LUQ<\/text>\n      <!-- Population -->\n      <rect x=\"10\" y=\"78\" width=\"140\" height=\"26\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"80\" y=\"95\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Typical patient<\/text>\n      <rect x=\"155\" y=\"78\" width=\"190\" height=\"26\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"250\" y=\"88\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Elderly, high-fibre diet,<\/text>\n      <text x=\"250\" y=\"99\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">psychiatric\/institutionalised<\/text>\n      <rect x=\"350\" y=\"78\" width=\"200\" height=\"26\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"450\" y=\"88\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Young woman, mobile caecum,<\/text>\n      <text x=\"450\" y=\"99\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">post-operative<\/text>\n      <!-- 1st line Rx -->\n      <rect x=\"10\" y=\"106\" width=\"140\" height=\"28\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"80\" y=\"124\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">1st-line (viable bowel)<\/text>\n      <rect x=\"155\" y=\"106\" width=\"190\" height=\"28\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"250\" y=\"117\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Endoscopic decompression<\/text>\n      <text x=\"250\" y=\"128\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">(flatus tube \/ sigmoidoscopy)<\/text>\n      <rect x=\"350\" y=\"106\" width=\"200\" height=\"28\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"450\" y=\"117\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Surgery (endoscopy rarely works)<\/text>\n      <text x=\"450\" y=\"128\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Detorsion \u00b1 caecopexy \/ resection<\/text>\n      <!-- Definitive -->\n      <rect x=\"10\" y=\"136\" width=\"140\" height=\"32\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"80\" y=\"156\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Definitive Rx<\/text>\n      <rect x=\"155\" y=\"136\" width=\"190\" height=\"32\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"250\" y=\"147\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Elective sigmoid resection after<\/text>\n      <text x=\"250\" y=\"158\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">bowel prep (high recurrence ~50%)<\/text>\n      <rect x=\"350\" y=\"136\" width=\"200\" height=\"32\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"450\" y=\"147\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Right hemicolectomy<\/text>\n      <text x=\"450\" y=\"158\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">+ primary anastomosis<\/text>\n    <\/svg>\n    <figcaption>\n      <strong>Key NEET trap:<\/strong> sigmoid volvulus first-line = endoscopic decompression (not immediate surgery). Surgery (Hartmann's procedure) is reserved for gangrenous bowel or failed decompression. Recurrence after decompression alone is ~50%, so elective sigmoid resection follows once the patient is optimised. Caecal volvulus almost always requires surgery.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q5: Appendicitis \u2014 Alvarado \/ MANTRELS score -->\n<div id=\"surg02-img5\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 190\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\" style=\"width:100%;max-width:560px;display:block;margin:0 auto\">\n      <rect x=\"0\" y=\"0\" width=\"560\" height=\"190\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Alvarado Score (MANTRELS) \u2014 Acute Appendicitis<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"320\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"335\" y=\"24\" width=\"60\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"400\" y=\"24\" width=\"150\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"170\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Clinical Feature (MANTRELS mnemonic)<\/text>\n      <text x=\"365\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Points<\/text>\n      <text x=\"475\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Interpretation<\/text>\n      <!-- Rows -->\n      <rect x=\"10\" y=\"48\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"61\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">M<\/tspan>igration of pain to RIF<\/text>\n      <rect x=\"335\" y=\"48\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"61\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">1<\/text>\n      <rect x=\"400\" y=\"48\" width=\"150\" height=\"54\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"475\" y=\"61\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Score 1\u20134:<\/text>\n\n      <rect x=\"10\" y=\"68\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"81\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">A<\/tspan>norexia<\/text>\n      <rect x=\"335\" y=\"68\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"81\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">1<\/text>\n      <text x=\"475\" y=\"75\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Low probability;<\/text>\n      <text x=\"475\" y=\"86\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">discharge \/ observe<\/text>\n\n      <rect x=\"10\" y=\"88\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"101\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">N<\/tspan>ausea \/ Vomiting<\/text>\n      <rect x=\"335\" y=\"88\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"101\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">1<\/text>\n      <rect x=\"400\" y=\"104\" width=\"150\" height=\"44\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"475\" y=\"117\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Score 5\u20136:<\/text>\n      <text x=\"475\" y=\"128\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Equivocal; CT\/USS<\/text>\n      <text x=\"475\" y=\"139\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">or active observation<\/text>\n\n      <rect x=\"10\" y=\"108\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"121\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">T<\/tspan>enderness RIF<\/text>\n      <rect x=\"335\" y=\"108\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"121\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">2<\/text>\n\n      <rect x=\"10\" y=\"128\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"141\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">R<\/tspan>ebound tenderness<\/text>\n      <rect x=\"335\" y=\"128\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"141\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">1<\/text>\n      <rect x=\"400\" y=\"150\" width=\"150\" height=\"34\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"475\" y=\"163\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Score 7\u201310:<\/text>\n      <text x=\"475\" y=\"174\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">High probability \u2192 OT<\/text>\n\n      <rect x=\"10\" y=\"148\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"161\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">E<\/tspan>levated temperature (&gt;37.3\u00b0C)<\/text>\n      <rect x=\"335\" y=\"148\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"161\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">1<\/text>\n\n      <rect x=\"10\" y=\"168\" width=\"320\" height=\"18\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"170\" y=\"181\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\"><tspan font-weight=\"bold\">L<\/tspan>eukocytosis (&gt;10,000) \/ <tspan font-weight=\"bold\">S<\/tspan>hift to left<\/text>\n      <rect x=\"335\" y=\"168\" width=\"60\" height=\"18\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"365\" y=\"181\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">2 \/ 1<\/text>\n    <\/svg>\n    <figcaption>\n      MANTRELS mnemonic maps to the Alvarado score (max 10). <strong>RIF tenderness (2 pts) and leukocytosis (2 pts)<\/strong> carry double weight. Score \u22657 = proceed to surgery without imaging in most settings. In women of reproductive age, USS (or MRI in pregnancy) is recommended even with high scores to exclude gynaecological pathology. The <strong>negative appendicectomy rate<\/strong> should ideally be &lt;20%.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"surg02\">\n\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Surgery Series &middot; Round 02<\/div>\n    <div class=\"mr-title\">\n      Lower GI Surgery<br><em>Small Bowel, Colon &amp; Appendix<\/em>\n    <\/div>\n    <div class=\"mr-subtitle\">Five cases &middot; Read carefully &middot; Trust your instinct<\/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=\"surg02-sentinel\"><\/div>\n\n  <div class=\"mr-progress\" id=\"surg02-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"surg02-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"surg02-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"surg02-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"surg02-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"surg02-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"surg02-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=\"surg02-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"surg02-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"surg02-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"surg02-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"surg02-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"surg02-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n\n<\/div><!-- end #surg02 -->\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'surg02';\n  var TOTAL = 5;\n  var MAX   = 20;\n  var LTRS  = ['A','B','C','D'];\n\n  var QS = [\n\n    {\n      id:      1,\n      tag:     'Lower GI &mdash; Intussusception',\n      stem:    'A <strong>14-month-old boy<\/strong> is brought to casualty with a <strong>6-hour history of intermittent, colicky abdominal pain<\/strong>. Between episodes he appears well, but during attacks he draws his knees up and screams inconsolably. His mother noticed <strong>blood and mucus in his nappy<\/strong> (\"redcurrant jelly\" stool). On examination, a <strong>sausage-shaped mass<\/strong> is felt in the right hypochondrium, and the RIF feels unusually empty (<em>Dance\\'s sign<\/em>). Abdominal ultrasound confirms a <strong>\"target sign\"<\/strong> (doughnut sign) in the right upper quadrant. Which is the most appropriate immediate management?',\n      correct: 'Pneumatic (air) or hydrostatic (saline\/contrast) enema reduction under radiological guidance',\n      opts: [\n        'Pneumatic (air) or hydrostatic (saline\/contrast) enema reduction under radiological guidance',\n        'Emergency laparotomy and manual reduction as first-line; enema is contraindicated in this age group',\n        'IV fluid resuscitation only; most intussusceptions in this age group resolve spontaneously within 24 hours',\n        'Barium enema is the investigation of choice and also serves as definitive treatment in all cases'\n      ],\n      exp:     'Intussusception \u2014 telescoping of a proximal bowel segment into the distal lumen \u2014 is the <strong>most common cause of intestinal obstruction in infants aged 3 months to 3 years<\/strong> (peak 5\u201310 months). The classic triad: <strong>colicky pain + redcurrant jelly stool + palpable sausage-shaped mass<\/strong>. Dance\\'s sign (empty RIF) occurs because the caecum is dragged into the right hypochondrium. <br><br><strong>Investigation:<\/strong> USS is first-line (target \/ doughnut sign = concentric rings of bowel wall on transverse section). <br><br><strong>Management \u2014 first-line (viable bowel, no peritonitis):<\/strong> <strong>Pneumatic (air) enema<\/strong> \u2014 success rate ~80\u201390%; performed under fluoroscopic guidance; air pressure limited to 120 mmHg. Hydrostatic enema (saline\/contrast) is equally effective. Three attempts are usually made. <br><br><strong>Surgery<\/strong> (manual reduction or resection) is reserved for: failed enema reduction, peritonitis, perforation, or gangrenous bowel. <br><br><strong>Lead points<\/strong> (important in older children and adults): Meckel\\'s diverticulum, polyp, lymphoma, Henoch-Sch&ouml;nlein purpura \u2014 always consider when intussusception occurs outside the typical infant age range. <br><br><strong>Recurrence<\/strong> after enema reduction ~10% \u2014 generally managed with repeat enema.',\n      imgId:   null\n    },\n\n    {\n      id:      2,\n      tag:     'Lower GI &mdash; Crohn\\'s vs UC',\n      stem:    'A <strong>24-year-old man<\/strong> presents with an 8-month history of <strong>right iliac fossa pain, diarrhoea (4\u20136 loose stools\/day, no blood), weight loss of 8 kg, and perianal fistulae<\/strong>. Colonoscopy shows <strong>skip lesions with cobblestone mucosa<\/strong> in the terminal ileum and caecum; the rectum is entirely normal. Biopsy reveals <strong>non-caseating granulomas<\/strong>. Bloods: CRP 68 mg\/L, Hb 9.8 g\/dL (microcytic). Which statement about the <em>surgical<\/em> management of this condition is most accurate?',\n      correct: 'Surgery is not curative; resection with primary anastomosis conserves bowel, but disease invariably recurs at the anastomotic site',\n      opts: [\n        'Surgery is not curative; resection with primary anastomosis conserves bowel, but disease invariably recurs at the anastomotic site',\n        'Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is the definitive curative operation of choice',\n        'Right hemicolectomy is curative as the disease is confined to the ileocaecal region in this patient',\n        'Surgery is avoided entirely in Crohn\\'s disease as it accelerates the autoimmune process'\n      ],\n      exp:     'This is <strong>Crohn\\'s disease<\/strong> \u2014 confirmed by skip lesions, rectal sparing, non-caseating granulomas, perianal involvement, and ileal\/caecal distribution. <br><br><strong>The cardinal surgical principle:<\/strong> surgery in Crohn\\'s is <strong>never curative<\/strong>. The disease recurs \u2014 typically at or just proximal to the anastomosis \u2014 in ~50\u201380% of patients within 10 years. The guiding philosophy is <strong>bowel conservation<\/strong> (resect as little as possible; avoid short bowel syndrome). <br><br><strong>Common surgical indications:<\/strong> failure of medical therapy, obstruction (strictureplasty may avoid resection), fistulae, abscess, perforation, bleeding, or cancer. <br><br><strong>IPAA (pouch surgery)<\/strong> is appropriate for <em>ulcerative colitis<\/em>, not Crohn\\'s \u2014 pouch failure rates in Crohn\\'s are very high (&gt;50%) due to recurrence in the pouch itself. <br><br><strong>Perianal Crohn\\'s<\/strong> (fistulae, skin tags, abscesses) is managed conservatively where possible \u2014 setons for fistulae, anti-TNF agents (infliximab), avoid aggressive surgery as healing is poor. <br><br>Compare with <strong>UC<\/strong>: proctocolectomy + IPAA is curative; toxic megacolon (UC complication) requires emergency colectomy; PSC is linked to UC not Crohn\\'s.',\n      imgId:   'surg02-img2'\n    },\n\n    {\n      id:      3,\n      tag:     'Lower GI &mdash; Peutz-Jeghers Syndrome',\n      stem:    'A <strong>19-year-old woman<\/strong> presents with recurrent colicky abdominal pain and two prior admissions for small bowel obstruction requiring operative intervention. She has <strong>hyperpigmented macules on her lips, buccal mucosa, and fingertips<\/strong> since childhood. Her father had similar pigmentation and died of a \"bowel tumour\" at age 48. Capsule endoscopy reveals multiple <strong>polyps throughout the small intestine with an arborising (tree-like) pattern<\/strong> on histology. Which statement about her condition is most accurate?',\n      correct: 'This is Peutz-Jeghers syndrome (STK11\/LKB1 mutation); hamartomatous polyps carry a significant lifetime malignancy risk affecting GI tract, breast, pancreas, and gonads',\n      opts: [\n        'This is Peutz-Jeghers syndrome (STK11\/LKB1 mutation); hamartomatous polyps carry a significant lifetime malignancy risk affecting GI tract, breast, pancreas, and gonads',\n        'This is familial adenomatous polyposis (APC mutation); colectomy at age 20 is mandatory to prevent colorectal cancer',\n        'This is juvenile polyposis syndrome; polyps are purely hamartomatous with no malignant potential, so surveillance alone is sufficient',\n        'This is Gardner syndrome; polyps are adenomatous and the extracolonic features are osteomas and desmoid tumours'\n      ],\n      exp:     '<strong>Peutz-Jeghers Syndrome (PJS)<\/strong> \u2014 autosomal dominant, caused by <strong>STK11 (LKB1) gene mutation<\/strong> on chromosome 19p. The hallmarks are: <br><br>&bull; <strong>Mucocutaneous melanin pigmentation<\/strong> \u2014 lips (pathognomonic), buccal mucosa, fingertips; fades after puberty except buccal pigmentation (which persists). <br>&bull; <strong>Hamartomatous polyps<\/strong> \u2014 predominantly small bowel (jejunum &gt; ileum &gt; duodenum), but also colon and stomach. Histology shows <strong>arborising smooth muscle core<\/strong> (tree-like branching) lined by normal epithelium \u2014 this is the diagnostic feature. <br>&bull; <strong>Complications:<\/strong> intussusception (MC acute complication \u2014 polyps act as lead points), obstruction, bleeding. <br><br><strong>Malignancy risk \u2014 critical exam point:<\/strong> PJS carries <strong>significantly elevated lifetime cancer risk<\/strong>: colorectal (39%), gastric (29%), small bowel (13%), pancreatic (36%), breast (54%), cervical, ovarian, and testicular (Sertoli cell tumours). The polyps themselves are hamartomas (low direct malignant potential), but there is increased risk of adenoma development alongside them. <br><br><strong>Surveillance:<\/strong> 2-yearly capsule endoscopy + colonoscopy from age 8; annual breast MRI from age 25; pancreatic MRI every 1\u20132 years from age 30. <br><br><strong>Quick polyposis recap:<\/strong> FAP = APC, adenomatous, colectomy mandatory; Gardner = FAP + osteomas\/desmoids; Turcot = FAP + brain tumours; Juvenile polyposis = SMAD4\/BMPR1A, hamartomas, moderate cancer risk; PJS = STK11, hamartomas + high extracolonic cancer risk.',\n      imgId:   null\n    },\n\n    {\n      id:      4,\n      tag:     'Lower GI &mdash; Sigmoid Volvulus',\n      stem:    'An <strong>elderly 72-year-old man<\/strong> from a psychiatric institution presents with a <strong>3-day history of absolute constipation, grossly distended abdomen, and vomiting<\/strong>. He is haemodynamically stable. Plain abdominal X-ray shows a <strong>massively dilated loop of colon arising from the pelvis and pointing toward the right upper quadrant<\/strong> \u2014 described as a \"coffee-bean sign.\" The caecum measures 4.2 cm. CT confirms a <strong>closed-loop sigmoid obstruction<\/strong> with no evidence of ischaemia or perforation. What is the most appropriate <em>immediate<\/em> management?',\n      correct: 'Rigid sigmoidoscopy or flexible sigmoidoscopy with passage of a flatus tube for endoscopic decompression',\n      opts: [\n        'Rigid sigmoidoscopy or flexible sigmoidoscopy with passage of a flatus tube for endoscopic decompression',\n        'Emergency Hartmann\\'s procedure (sigmoid resection + end colostomy) as first-line management',\n        'Barium or water-soluble contrast enema to reduce the volvulus under fluoroscopic guidance',\n        'Conservative management with nasogastric decompression, IV fluids, and rectal tube insertion only'\n      ],\n      exp:     'Sigmoid volvulus is the <strong>most common type of colonic volvulus<\/strong> (80%) and the most common cause of large bowel obstruction in Africa and India (where high-fibre diets and long sigmoid mesocolons are common). The coffee-bean (or omega\/bent inner-tube) sign on AXR points toward the <strong>right upper quadrant<\/strong> \u2014 this directionality distinguishes it from caecal volvulus. <br><br><strong>Immediate management (viable bowel, no peritonitis):<\/strong> <strong>Endoscopic decompression<\/strong> \u2014 rigid or flexible sigmoidoscopy with a flatus tube left in situ. Success rate ~70\u201390%. The rush of gas and faecal matter confirms successful derotation. The tube is left for 24\u201348 hours. <br><br><strong>Definitive treatment:<\/strong> elective sigmoid resection after bowel preparation (recurrence without surgery is ~50%). <br><br><strong>Surgery (Hartmann\\'s procedure) is indicated when:<\/strong> gangrenous bowel, perforation, peritonitis, or failed endoscopic decompression. Hartmann\\'s = sigmoid resection + end colostomy + rectal stump closure (avoids primary anastomosis in unprepared, contaminated field). <br><br><strong>Caecal volvulus<\/strong> (coffee-bean in RLQ, points toward LUQ) does <em>not<\/em> respond to endoscopy \u2014 always needs surgery (right hemicolectomy or caecopexy). <br><br><strong>Contraindication to endoscopy:<\/strong> any sign of gangrene, perforation, or peritonitis \u2192 go straight to surgery.',\n      imgId:   'surg02-img4'\n    },\n\n    {\n      id:      5,\n      tag:     'Lower GI &mdash; Acute Appendicitis',\n      stem:    'A <strong>17-year-old boy<\/strong> presents with a <strong>24-hour history of periumbilical pain that has now shifted to the right iliac fossa<\/strong>. He has anorexia, one episode of vomiting, and a low-grade fever of 37.8&deg;C. Examination reveals <strong>guarding and rebound tenderness at McBurney\\'s point<\/strong>. His MANTRELS (Alvarado) score is calculated as <strong>8\/10<\/strong>. WBC is 14,200 cells\/&mu;L with a neutrophil shift. Urine dipstick is normal. Which is the most appropriate next step?',\n      correct: 'Proceed to appendicectomy without further imaging; Alvarado score &#x2265;7 in a male warrants direct surgical intervention',\n      opts: [\n        'Proceed to appendicectomy without further imaging; Alvarado score &#x2265;7 in a male warrants direct surgical intervention',\n        'CT abdomen is mandatory before any surgical intervention, regardless of clinical score, to confirm the diagnosis',\n        'Admit for 24-hour active observation and repeat examination; appendicectomy only if score rises to 10',\n        'Ultrasound abdomen is the preferred investigation given the high radiation dose of CT in this age group'\n      ],\n      exp:     'An <strong>Alvarado (MANTRELS) score of 7\u201310<\/strong> represents high probability of acute appendicitis and is an indication for <strong>direct surgical intervention<\/strong> without mandatory imaging \u2014 particularly in males, where the differential is narrower. <br><br><strong>MANTRELS mnemonic (max 10):<\/strong> Migration to RIF (1) + Anorexia (1) + Nausea\/vomiting (1) + Tenderness RIF (2) + Rebound tenderness (1) + Elevated temperature (1) + Leukocytosis (2) + Shift to left (1). <br><br><strong>Score interpretation:<\/strong> 1\u20134 = low (discharge\/observe); 5\u20136 = equivocal (imaging\/observe); 7\u201310 = high (proceed to OT). <br><br><strong>Why imaging may be skipped in males with score &#x2265;7:<\/strong> the differential in young males is narrow (mesenteric adenitis, Meckel\\'s diverticulitis). The negative appendicectomy rate of ~10\u201315% is considered acceptable. <br><br><strong>When imaging IS recommended:<\/strong> females of reproductive age (exclude ectopic pregnancy, ovarian torsion, PID), children, elderly, immunocompromised, equivocal scores (5\u20136), or atypical presentations. USS first in females\/children (avoids radiation); CT if USS inconclusive. <br><br><strong>Operation:<\/strong> laparoscopic appendicectomy (preferred \u2014 faster recovery, lower wound infection, better visualisation). Open (Lanz \/ McBurney\\'s incision) remains an alternative. <br><br><strong>Ochsner-Sherren (interval) regimen:<\/strong> for appendicular mass (palpable RIF mass at 3\u20135 days, no peritonitis) \u2014 conservative management with antibiotics; interval appendicectomy at 6\u20138 weeks.',\n      imgId:   'surg02-img5'\n    }\n\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(suffix) { return byId(NS + '-' + suffix); }\n\n  function shuffleArr(arr) {\n    var a = arr.slice(), i, j, tmp;\n    for (i = a.length - 1; i > 0; i--) {\n      j = Math.floor(Math.random() * (i + 1));\n      tmp = a[i]; a[i] = a[j]; a[j] = tmp;\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, wLine, wPip, line, pip;\n    cont.innerHTML = '';\n    for (i = 0; i < QS.length; i++) {\n      q = QS[i];\n      if (i > 0) {\n        wLine = document.createElement('div');\n        wLine.className = 'mr-pip-wrap';\n        line = document.createElement('div');\n        line.className = 'mr-pip-line';\n        line.id = NS + '-pl' + q.id;\n        wLine.appendChild(line);\n        cont.appendChild(wLine);\n      }\n      wPip = document.createElement('div');\n      wPip.className = 'mr-pip-wrap';\n      pip = document.createElement('div');\n      pip.className = 'mr-pip';\n      pip.id = NS + '-pip' + q.id;\n      pip.textContent = String(q.id);\n      wPip.appendChild(pip);\n      cont.appendChild(wPip);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, numDiv, meta, tag, stem,\n        rule, optsDiv, expDiv, lbl, txt, imgDiv, imgSrc, j,\n        optEl, ltrSpan, txtSpan;\n\n    cont = gid('cases');\n    cont.innerHTML = '';\n    answers = {}; answered = 0; shuffled = {}; done = false;\n    gid('score').style.display = 'none';\n    buildPips();\n\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');\n      card.className = 'mr-case';\n\n      top = document.createElement('div');\n      top.className = 'mr-case-top';\n\n      numDiv = document.createElement('div');\n      numDiv.className = 'mr-num';\n      numDiv.textContent = q.id < 10 ? 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Come back tomorrow.']\n    ];\n    gid('verdict').textContent = verdicts[4][1];\n    for (vi = 0; vi < verdicts.length; vi++) {\n      if (c >= verdicts[vi][0]) {\n        gid('verdict').innerHTML = verdicts[vi][1];\n        break;\n      }\n    }\n\n    gid('ct-c').textContent = '\\u2705 ' + c + ' Correct';\n    gid('ct-w').textContent = '\\u274C ' + w + ' Wrong';\n    gid('ct-s').textContent = '\\u23ED ' + s + ' Skipped';\n\n    sc = gid('score');\n    sc.style.display = 'block';\n    sc.scrollIntoView({ behavior: 'smooth', block: 'center' });\n  }\n\n  function tryInit() {\n    var sentinel = document.getElementById(NS + '-sentinel');\n    var submit   = document.getElementById(NS + '-submit');\n    var retry    = document.getElementById(NS + '-retry');\n    if (!sentinel || !submit || !retry) {\n      setTimeout(tryInit, 80);\n      return;\n    }\n    submit.addEventListener('click', showScore);\n    retry.addEventListener('click', function () {\n      build();\n      window.scrollTo(0, 0);\n    });\n    var bar = document.getElementById(NS + '-progress');\n    if (bar && window.IntersectionObserver) {\n      new IntersectionObserver(function (entries) {\n        bar.className = entries[0].isIntersecting ? 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