{"id":37059,"date":"2026-06-17T04:07:31","date_gmt":"2026-06-16T22:37:31","guid":{"rendered":"https:\/\/atsixty.com\/?p=37059"},"modified":"2026-06-17T22:49:57","modified_gmt":"2026-06-17T17:19:57","slug":"hepatobiliary-pancreas","status":"publish","type":"post","link":"https:\/\/atsixty.com\/index.php\/clinical\/surgery\/hepatobiliary-pancreas\/","title":{"rendered":"Hepatobiliary &amp; Pancreas"},"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 Hepatobiliary &amp; Pancreas<\/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#surg03 *,#surg03 *::before,#surg03 *::after{box-sizing:border-box;margin:0;padding:0}\n#surg03{\n  --surg:#2C5F8A;--surg-light:#3A78A8;--surg-pale:#EBF2F8;--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;font-size:16px;color:var(--ink);\n  background:var(--cream);line-height:1.7;padding:0 0 64px;\n}\n#surg03 .mr-header{background:var(--surg);color:#EEF5FA;padding:34px 24px 28px;text-align:center}\n#surg03 .mr-eyebrow{font-size:0.68rem;letter-spacing:0.18em;text-transform:uppercase;font-weight:600;opacity:0.65;margin-bottom:10px}\n#surg03 .mr-title{font-family:'Playfair Display',serif;font-size:1.75rem;font-weight:700;line-height:1.2;margin-bottom:4px}\n#surg03 .mr-title em{font-style:italic;font-weight:400;opacity:0.88}\n#surg03 .mr-subtitle{font-size:0.82rem;opacity:0.7;margin-top:8px;font-style:italic}\n#surg03 .mr-chips{display:flex;justify-content:center;gap:10px;margin-top:18px;flex-wrap:wrap}\n#surg03 .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#surg03 .mr-sentinel{height:1px}\n#surg03 .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#surg03 .mr-progress.visible{display:block}\n#surg03 .mr-prog-inner{max-width:720px;margin:0 auto;display:flex;align-items:center;justify-content:center}\n#surg03 .mr-pips{display:flex;align-items:center;justify-content:center}\n#surg03 .mr-pip-wrap{display:flex;align-items:center}\n#surg03 .mr-pip-line{width:28px;height:2px;background:var(--line);transition:background 0.35s}\n#surg03 .mr-pip-line.done{background:var(--surg)}\n#surg03 .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#surg03 .mr-pip.correct{background:var(--correct-border);border-color:var(--correct-border);color:#fff}\n#surg03 .mr-pip.wrong{background:var(--wrong-border);border-color:var(--wrong-border);color:#fff}\n#surg03 .mr-body{max-width:720px;margin:0 auto;padding:0 16px}\n#surg03 .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#surg03 .mr-case-top{padding:16px 20px 14px;display:flex;gap:14px;align-items:flex-start}\n#surg03 .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#surg03 .mr-meta{flex:1}\n#surg03 .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#surg03 .mr-stem{font-size:0.94rem;color:var(--ink);line-height:1.72}\n#surg03 .mr-stem strong{font-weight:600}\n#surg03 .mr-stem em{font-style:italic}\n#surg03 .mr-rule{height:1px;background:var(--line);margin:0 20px}\n#surg03 .mr-opts{padding:12px 20px 16px;display:flex;flex-direction:column;gap:8px}\n#surg03 .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#surg03 .mr-opt:hover{border-color:var(--surg);background:var(--surg-pale)}\n#surg03 .mr-opt.locked{cursor:default}\n#surg03 .mr-opt.locked:hover{border-color:var(--line);background:var(--warm)}\n#surg03 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.mr-opt-text{font-size:0.9rem;color:var(--ink-mid);line-height:1.58}\n#surg03 .mr-opt.correct .mr-opt-text{color:var(--correct);font-weight:600}\n#surg03 .mr-opt.wrong .mr-opt-text{color:var(--wrong)}\n#surg03 .mr-exp{display:none;border-top:1px solid #b8d4e4;background:linear-gradient(180deg,#e4f0f7 0%,#f0f7fb 100%);padding:13px 20px 15px}\n#surg03 .mr-exp-lbl{font-size:0.61rem;font-weight:700;letter-spacing:0.12em;text-transform:uppercase;color:#1a5070;margin-bottom:6px}\n#surg03 .mr-exp-text{font-size:0.86rem;color:#12324A;line-height:1.68}\n#surg03 .mr-exp-text strong{font-weight:600}\n#surg03 .mr-exp-text em{font-style:italic}\n#surg03 .mr-img-wrap{margin-top:14px;background:var(--warm);border:1px solid var(--line);border-radius:8px;padding:14px;text-align:center}\n#surg03 .mr-img-wrap figcaption{font-size:0.73rem;color:var(--ink-soft);font-style:italic;margin-top:8px;line-height:1.4}\n#surg03 .mr-submit-wrap{text-align:center;padding:28px 16px 8px}\n#surg03 .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#surg03 .mr-btn:hover{background:var(--surg-dark)}\n#surg03 .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#surg03 .mr-score-in{padding:28px 24px;text-align:center}\n#surg03 .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#surg03 .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#surg03 .mr-ring::before{content:'';position:absolute;width:76px;height:76px;border-radius:50%;background:var(--warm)}\n#surg03 .mr-ring-in{position:relative;display:flex;flex-direction:column;align-items:center;line-height:1.2}\n#surg03 .mr-ring-pct{font-family:'Playfair Display',serif;font-size:1.3rem;font-weight:700;color:var(--surg)}\n#surg03 .mr-ring-sub{font-size:0.54rem;color:var(--ink-soft);text-transform:uppercase;letter-spacing:0.06em}\n#surg03 .mr-score-title{font-family:'Playfair Display',serif;font-size:1.15rem;font-weight:700;color:var(--ink);margin-bottom:4px}\n#surg03 .mr-score-net{font-size:0.9rem;color:var(--surg);font-weight:600;margin-bottom:4px}\n#surg03 .mr-verdict{font-size:0.83rem;color:var(--ink-soft);font-style:italic;margin-bottom:18px;padding:0 12px}\n#surg03 .mr-bands{display:flex;justify-content:center;gap:10px;flex-wrap:wrap}\n#surg03 .mr-band{padding:5px 13px;border-radius:16px;font-size:0.78rem;font-weight:600}\n#surg03 .mr-band-c{background:var(--correct-bg);color:var(--correct)}\n#surg03 .mr-band-w{background:var(--wrong-bg);color:var(--wrong)}\n#surg03 .mr-band-s{background:var(--surg-pale);color:var(--surg)}\n#surg03 .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#surg03 .mr-retry:hover{background:var(--surg);color:#EEF5FA}\n@media(max-width:480px){#surg03 .mr-title{font-size:1.4rem}#surg03 .mr-num{font-size:1.7rem}#surg03 .mr-stem{font-size:0.9rem}#surg03 .mr-opt-text{font-size:0.86rem}}\n<\/style>\n\n<!-- SVG Q1: Cholangitis \u2014 Charcot's triad \/ Reynold's pentad -->\n<div id=\"surg03-img1\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 170\" 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=\"170\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Acute Cholangitis \u2014 Clinical Grading &amp; Features<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"130\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"145\" y=\"24\" width=\"220\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"370\" y=\"24\" width=\"180\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <text x=\"75\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Syndrome<\/text>\n      <text x=\"255\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Features<\/text>\n      <text x=\"460\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Implication<\/text>\n      <!-- Charcot -->\n      <rect x=\"10\" y=\"48\" width=\"130\" height=\"36\" rx=\"2\" fill=\"#dce8f0\"\/>\n      <text x=\"75\" y=\"62\" text-anchor=\"middle\" fill=\"#1C3D52\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Charcot's Triad<\/text>\n      <text x=\"75\" y=\"75\" text-anchor=\"middle\" fill=\"#2C5F8A\" font-size=\"7\" font-family=\"Georgia,serif\">(RUQ pain + fever + jaundice)<\/text>\n      <rect x=\"145\" y=\"48\" width=\"220\" height=\"36\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"255\" y=\"62\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Biliary colic + fever\/rigors + obstructive<\/text>\n      <text x=\"255\" y=\"75\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">jaundice (Courvoisier's sign absent here)<\/text>\n      <rect x=\"370\" y=\"48\" width=\"180\" height=\"36\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"460\" y=\"62\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Moderate cholangitis;<\/text>\n      <text x=\"460\" y=\"75\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">ERCP within 24\u201348 hrs<\/text>\n      <!-- Reynold -->\n      <rect x=\"10\" y=\"86\" width=\"130\" height=\"46\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"75\" y=\"100\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Reynold's Pentad<\/text>\n      <text x=\"75\" y=\"113\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\">(Triad + confusion<\/text>\n      <text x=\"75\" y=\"124\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7\" font-family=\"Georgia,serif\">+ hypotension)<\/text>\n      <rect x=\"145\" y=\"86\" width=\"220\" height=\"46\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"255\" y=\"100\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">All 3 of Charcot's + altered<\/text>\n      <text x=\"255\" y=\"112\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">sensorium + septic shock<\/text>\n      <text x=\"255\" y=\"124\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Mortality &gt;50% if untreated<\/text>\n      <rect x=\"370\" y=\"86\" width=\"180\" height=\"46\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"460\" y=\"100\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Severe \/ Grade III;<\/text>\n      <text x=\"460\" y=\"112\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">ICU + emergency ERCP<\/text>\n      <text x=\"460\" y=\"124\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">within 12 hrs (or PTBD)<\/text>\n      <!-- Causes row -->\n      <rect x=\"10\" y=\"134\" width=\"540\" height=\"30\" rx=\"3\" fill=\"#2C5F8A\" opacity=\"0.10\"\/>\n      <text x=\"280\" y=\"147\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">MC cause: Choledocholithiasis (stones in CBD) \u00b7 Others: benign\/malignant stricture, post-ERCP, Caroli disease, biliary stents<\/text>\n      <text x=\"280\" y=\"159\" text-anchor=\"middle\" fill=\"#2C5F8A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Tokyo Guidelines grade I (mild) \u2192 antibiotics + elective ERCP \u00b7 Grade II (moderate) \u2192 early ERCP 24\u201348h \u00b7 Grade III \u2192 ICU + emergency drainage<\/text>\n    <\/svg>\n    <figcaption>\n      <strong>NEET trap:<\/strong> Charcot's triad = pain + fever + jaundice (3 features). Reynold's pentad adds confusion + hypotension (5 features = septic cholangitis). The cause is almost always <strong>choledocholithiasis<\/strong> \u2014 CBD stones. Treatment is biliary decompression: ERCP + sphincterotomy + stone extraction is first-line. Surgery (CBD exploration) is reserved for failed ERCP.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q2: Ranson's Criteria -->\n<div id=\"surg03-img2\" style=\"display:none\">\n  <figure class=\"mr-img-wrap\">\n    <svg viewBox=\"0 0 560 185\" 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=\"185\" rx=\"8\" fill=\"#f0f5f9\"\/>\n      <text x=\"14\" y=\"18\" fill=\"#1A2A38\" font-size=\"9.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Ranson's Criteria \u2014 Acute Pancreatitis Severity<\/text>\n      <!-- Headers -->\n      <rect x=\"10\" y=\"24\" width=\"265\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"280\" y=\"24\" width=\"270\" height=\"22\" rx=\"3\" fill=\"#1E4464\"\/>\n      <text x=\"142\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">On Admission (5 criteria)<\/text>\n      <text x=\"415\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">At 48 Hours (6 criteria)<\/text>\n      <!-- Admission criteria -->\n      <rect x=\"10\" y=\"48\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"142\" y=\"62\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Age &gt; 55 years<\/text>\n      <rect x=\"10\" y=\"70\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#eef4f8\"\/>\n      <text x=\"142\" y=\"84\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">WBC &gt; 16,000 \/mm\u00b3<\/text>\n      <rect x=\"10\" y=\"92\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"142\" y=\"106\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Blood glucose &gt; 11 mmol\/L (200 mg\/dL)<\/text>\n      <rect x=\"10\" y=\"114\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#eef4f8\"\/>\n      <text x=\"142\" y=\"128\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">LDH &gt; 350 IU\/L<\/text>\n      <rect x=\"10\" y=\"136\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#f0f5f9\"\/>\n      <text x=\"142\" y=\"150\" text-anchor=\"middle\" fill=\"#12324A\" font-size=\"7.5\" font-family=\"Georgia,serif\">AST &gt; 250 IU\/L<\/text>\n      <!-- 48hr criteria -->\n      <rect x=\"280\" y=\"48\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"415\" y=\"62\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">HCT fall &gt; 10%<\/text>\n      <rect x=\"280\" y=\"70\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"84\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">BUN rise &gt; 5 mg\/dL<\/text>\n      <rect x=\"280\" y=\"92\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"415\" y=\"106\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Serum Ca\u00b2\u207a &lt; 2 mmol\/L (8 mg\/dL)<\/text>\n      <rect x=\"280\" y=\"114\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"128\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">PaO\u2082 &lt; 60 mmHg<\/text>\n      <rect x=\"280\" y=\"136\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf3e0\"\/>\n      <text x=\"415\" y=\"150\" text-anchor=\"middle\" fill=\"#7A4A00\" font-size=\"7.5\" font-family=\"Georgia,serif\">Base deficit &gt; 4 mEq\/L<\/text>\n      <rect x=\"280\" y=\"158\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"172\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Fluid sequestration &gt; 6 L<\/text>\n      <!-- Score interpretation bar -->\n      <rect x=\"10\" y=\"158\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#2C5F8A\" opacity=\"0.12\"\/>\n      <text x=\"142\" y=\"168\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"7\" font-family=\"Georgia,serif\" font-weight=\"bold\">Score: &lt;3 = Mild \u00b7 3\u20134 = Moderate \u00b7 \u22655 = Severe (&gt;50% mortality)<\/text>\n      <text x=\"142\" y=\"178\" text-anchor=\"middle\" fill=\"#2C5F8A\" font-size=\"7\" font-family=\"Georgia,serif\">Mnemonic (admission): GA LAW \u00b7 (48h): C HOBF<\/text>\n    <\/svg>\n    <figcaption>\n      Ranson's 11 criteria (5 on admission + 6 at 48 hours). <strong>Cannot be calculated until 48 hours have elapsed<\/strong> \u2014 a key limitation. Score \u22653 = severe pancreatitis \u2192 ICU. <strong>Best single marker of severity:<\/strong> CRP &gt;150 mg\/L at 48 hours. CT severity index (Balthazar + necrosis score) is used for imaging-based grading. <strong>Remember:<\/strong> amylase and lipase levels do NOT correlate with severity.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<!-- SVG Q5: Carcinoma Pancreas \u2014 double duct sign + Whipple's -->\n<div id=\"surg03-img5\" 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\">Carcinoma Pancreas \u2014 Resectability &amp; Whipple's Procedure<\/text>\n      <!-- Resectability criteria header -->\n      <rect x=\"10\" y=\"24\" width=\"265\" height=\"22\" rx=\"3\" fill=\"#2C5F8A\"\/>\n      <rect x=\"280\" y=\"24\" width=\"270\" height=\"22\" rx=\"3\" fill=\"#B83232\"\/>\n      <text x=\"142\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Resectable (surgery possible)<\/text>\n      <text x=\"415\" y=\"39\" text-anchor=\"middle\" fill=\"#EEF5FA\" font-size=\"8\" font-family=\"Georgia,serif\" font-weight=\"bold\">Unresectable (palliation only)<\/text>\n      <!-- Resectable -->\n      <rect x=\"10\" y=\"48\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"142\" y=\"62\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">No distant metastases<\/text>\n      <rect x=\"10\" y=\"70\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"142\" y=\"84\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">No involvement of SMA \/ coeliac axis<\/text>\n      <rect x=\"10\" y=\"92\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"142\" y=\"106\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Patent SMV \/ portal vein (or reconstructable)<\/text>\n      <rect x=\"10\" y=\"114\" width=\"265\" height=\"20\" rx=\"2\" fill=\"#eaf4f0\"\/>\n      <text x=\"142\" y=\"128\" text-anchor=\"middle\" fill=\"#2D6B47\" font-size=\"7.5\" font-family=\"Georgia,serif\">Only 15\u201320% of cases at presentation<\/text>\n      <!-- Unresectable -->\n      <rect x=\"280\" y=\"48\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"62\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Liver \/ peritoneal \/ distant mets<\/text>\n      <rect x=\"280\" y=\"70\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"84\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">SMA \/ coeliac axis encasement<\/text>\n      <rect x=\"280\" y=\"92\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"106\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">SMV \/ portal vein occlusion<\/text>\n      <rect x=\"280\" y=\"114\" width=\"270\" height=\"20\" rx=\"2\" fill=\"#fdf0f0\"\/>\n      <text x=\"415\" y=\"128\" text-anchor=\"middle\" fill=\"#B83232\" font-size=\"7.5\" font-family=\"Georgia,serif\">Palliation: biliary stent \/ HJ + GJ<\/text>\n      <!-- Whipple box -->\n      <rect x=\"10\" y=\"136\" width=\"540\" height=\"32\" rx=\"3\" fill=\"#2C5F8A\" opacity=\"0.10\"\/>\n      <text x=\"280\" y=\"149\" text-anchor=\"middle\" fill=\"#1E4464\" font-size=\"7.5\" font-family=\"Georgia,serif\" font-weight=\"bold\">Whipple's (Pancreaticoduodenectomy): remove head of pancreas + duodenum + CBD + gallbladder + distal stomach<\/text>\n      <text x=\"280\" y=\"161\" text-anchor=\"middle\" fill=\"#2C5F8A\" font-size=\"7.5\" font-family=\"Georgia,serif\">Reconstruct: pancreaticojejunostomy + hepaticojejunostomy + gastrojejunostomy \u00b7 MC complication: delayed gastric emptying \u00b7 Dreaded: pancreatic fistula<\/text>\n    <\/svg>\n    <figcaption>\n      <strong>Double-duct sign<\/strong> on MRCP\/ERCP = simultaneous dilatation of CBD and pancreatic duct at the ampulla \u2014 highly suggestive of periampullary\/pancreatic head carcinoma. <strong>Courvoisier's law:<\/strong> painless, palpable gallbladder + jaundice = malignant obstruction (not stones, because chronic stone disease causes fibrosis of the GB wall). <strong>5-year survival after Whipple's:<\/strong> ~20\u201325% \u2014 best among pancreatic cancers.\n    <\/figcaption>\n  <\/figure>\n<\/div>\n\n<div id=\"surg03\">\n  <div class=\"mr-header\">\n    <div class=\"mr-eyebrow\">Morning Rounds &middot; Surgery Series &middot; Round 03<\/div>\n    <div class=\"mr-title\">Hepatobiliary &amp; Pancreas<br><em>Liver, Biliary Tract &amp; Pancreas<\/em><\/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=\"surg03-sentinel\"><\/div>\n  <div class=\"mr-progress\" id=\"surg03-progress\">\n    <div class=\"mr-prog-inner\">\n      <div class=\"mr-pips\" id=\"surg03-pips\"><\/div>\n    <\/div>\n  <\/div>\n\n  <div class=\"mr-body\">\n    <div id=\"surg03-cases\"><\/div>\n    <div class=\"mr-submit-wrap\">\n      <button class=\"mr-btn\" id=\"surg03-submit\">Submit for Debrief<\/button>\n    <\/div>\n    <div class=\"mr-score\" id=\"surg03-score\">\n      <div class=\"mr-score-in\">\n        <div class=\"mr-score-ey\">Round Complete<\/div>\n        <div class=\"mr-ring\" id=\"surg03-ring\">\n          <div class=\"mr-ring-in\">\n            <span class=\"mr-ring-pct\" id=\"surg03-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=\"surg03-net\"><\/div>\n        <div class=\"mr-verdict\" id=\"surg03-verdict\"><\/div>\n        <div class=\"mr-bands\">\n          <span class=\"mr-band mr-band-c\" id=\"surg03-ct-c\"><\/span>\n          <span class=\"mr-band mr-band-w\" id=\"surg03-ct-w\"><\/span>\n          <span class=\"mr-band mr-band-s\" id=\"surg03-ct-s\"><\/span>\n        <\/div>\n        <button class=\"mr-retry\" id=\"surg03-retry\">&#8635; New Round<\/button>\n      <\/div>\n    <\/div>\n  <\/div>\n<\/div>\n\n<script>\n(function () {\n  'use strict';\n\n  var NS    = 'surg03';\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:   'Hepatobiliary &mdash; Acute Cholangitis',\n      stem:  'A <strong>48-year-old woman<\/strong> with known cholelithiasis presents with a <strong>3-day history of right upper quadrant pain, high-grade fever with rigors, and progressive jaundice<\/strong>. On examination she is febrile (39.4&deg;C), icteric, and has marked RUQ tenderness. Bloods: bilirubin 94 &mu;mol\/L, ALP 420 IU\/L, WBC 18,400\/mm&sup3;. USS shows a <strong>dilated CBD (12 mm) with echogenic material within<\/strong> and a contracted, thick-walled gallbladder. She is haemodynamically stable and alert. What is the most appropriate management sequence?',\n      correct: 'IV antibiotics + IV fluids, followed by ERCP with sphincterotomy and CBD stone extraction within 24&ndash;48 hours',\n      opts: [\n        'IV antibiotics + IV fluids, followed by ERCP with sphincterotomy and CBD stone extraction within 24&ndash;48 hours',\n        'Emergency laparotomy with CBD exploration and T-tube placement as first-line management',\n        'Urgent laparoscopic cholecystectomy within 6 hours to remove the source of biliary sepsis',\n        'MRCP first to confirm choledocholithiasis, then elective ERCP in 2 weeks once infection is controlled'\n      ],\n      exp:   'This is <strong>acute cholangitis<\/strong> \u2014 Charcot\\'s triad of RUQ pain + fever + jaundice in the context of CBD obstruction (dilated CBD + stones on USS). The grade is <strong>moderate (Grade II)<\/strong> by Tokyo Guidelines \u2014 stable haemodynamics + no organ dysfunction. <br><br><strong>Management:<\/strong> (1) Resuscitation \u2014 IV fluids, analgesia; (2) Broad-spectrum IV antibiotics covering Gram-negative enteric organisms and anaerobes (e.g. piperacillin-tazobactam, or ceftriaxone + metronidazole); (3) <strong>Early ERCP within 24\u201348 hours<\/strong> \u2014 sphincterotomy + stone extraction + biliary drainage is the definitive intervention. <br><br><strong>If Reynold\\'s pentad<\/strong> (adds confusion + hypotension = Grade III severe cholangitis) \u2192 ICU + <strong>emergency ERCP within 12 hours<\/strong> or PTBD (percutaneous transhepatic biliary drainage) if ERCP not feasible. <br><br><strong>Why not emergency surgery?<\/strong> ERCP has replaced surgical CBD exploration as first-line \u2014 equivalent efficacy, much lower morbidity. Surgery (laparoscopic CBD exploration or open) is reserved for failed ERCP. <br><br><strong>Why not cholecystectomy now?<\/strong> Cholecystectomy removes the gallbladder but does not drain the CBD. The CBD must be cleared first. Cholecystectomy is deferred to the same admission or electively after recovery. <br><br><strong>MC cause:<\/strong> choledocholithiasis (~85%). Others: biliary strictures, malignancy, post-ERCP, biliary stents, Caroli disease.',\n      imgId: 'surg03-img1'\n    },\n\n    {\n      id:    2,\n      tag:   'Hepatobiliary &mdash; Acute Pancreatitis',\n      stem:  'A <strong>42-year-old man<\/strong> presents with severe <strong>epigastric pain radiating to the back<\/strong>, vomiting, and inability to keep any oral intake. He consumes approximately 60 g alcohol per day. Serum lipase is <strong>4\u00d7 the upper limit of normal<\/strong>. USS shows no gallstones; CBD is not dilated. He is febrile (38.6&deg;C), tachycardic (PR 112), and has periumbilical bruising (Cullen\\'s sign). At 48 hours, his Ranson\\'s score is calculated as <strong>4<\/strong>. Which statement about his further management is most accurate?',\n      correct: 'He has moderate-severe pancreatitis; manage with aggressive IV fluid resuscitation, early enteral nutrition via nasojejunal tube, and monitor for local complications',\n      opts: [\n        'He has moderate-severe pancreatitis; manage with aggressive IV fluid resuscitation, early enteral nutrition via nasojejunal tube, and monitor for local complications',\n        'Ranson\\'s score of 4 mandates immediate surgical necrosectomy to prevent infected pancreatic necrosis',\n        'Total parenteral nutrition (TPN) is preferred over enteral nutrition to rest the pancreas in severe pancreatitis',\n        'Prophylactic antibiotics (meropenem) should be started immediately to prevent secondary infection of necrosis'\n      ],\n      exp:   '<strong>Ranson\\'s score 3\u20134 = moderate-severe pancreatitis<\/strong> (predicted mortality ~15%). Score \u22655 = severe (&gt;50% mortality). <br><br><strong>Key management principles:<\/strong> <br>&bull; <strong>Aggressive IV fluid resuscitation<\/strong> \u2014 Ringer\\'s lactate preferred over normal saline (reduces systemic inflammation); 250\u2013500 mL\/hour initially. Guided by urine output (&gt;0.5 mL\/kg\/hr) and haematocrit trends. <br>&bull; <strong>Early enteral nutrition<\/strong> (within 24\u201348 hrs) via nasogastric or <strong>nasojejunal<\/strong> tube \u2014 superior to TPN; maintains gut barrier, reduces bacterial translocation, reduces infectious complications and mortality. TPN is reserved for those who cannot tolerate enteral feeding. <br>&bull; <strong>No prophylactic antibiotics<\/strong> \u2014 not recommended in current guidelines (NICE, IAP); they do not prevent infected necrosis and promote resistant organisms. Antibiotics are given only when infection is confirmed or strongly suspected. <br><br><strong>Cullen\\'s sign<\/strong> (periumbilical bruising) and Grey Turner\\'s sign (flank bruising) indicate retroperitoneal haemorrhage \u2014 associated with haemorrhagic pancreatitis; poor prognosis. <br><br><strong>Local complications (Atlanta classification):<\/strong> acute peripancreatic fluid collection \u2192 pseudocyst (if persists &gt;4 weeks, walled off); acute necrotic collection \u2192 walled-off necrosis (WON). <br><br><strong>Surgery<\/strong> (necrosectomy) is indicated only for: confirmed infected necrosis failing antibiotics, or if step-up approach (percutaneous drainage \u2192 endoscopic\/surgical debridement) fails. <strong>Never operate in first 2 weeks<\/strong> \u2014 demarcation of necrosis is incomplete.',\n      imgId: 'surg03-img2'\n    },\n\n    {\n      id:    3,\n      tag:   'Hepatobiliary &mdash; Biliary Atresia',\n      stem:  'A <strong>6-week-old female infant<\/strong> is referred with <strong>persistent jaundice since birth, acholic (pale\/clay-coloured) stools, and dark urine<\/strong>. She is otherwise thriving; weight gain is adequate. Examination reveals hepatomegaly and mild icterus. Bloods: conjugated bilirubin 68 &mu;mol\/L (predominantly direct), GGT markedly elevated. USS liver is normal in size with no intrahepatic biliary dilatation; the gallbladder is not visualised. HIDA (hepatobiliary iminodiacetic acid) scan shows <strong>no excretion of tracer into the bowel<\/strong> at 24 hours. What is the most appropriate next step?',\n      correct: 'Intraoperative cholangiogram + Kasai hepatoportoenterostomy if biliary atresia confirmed; performed before 60 days of age for best outcome',\n      opts: [\n        'Intraoperative cholangiogram + Kasai hepatoportoenterostomy if biliary atresia confirmed; performed before 60 days of age for best outcome',\n        'ERCP to visualise and dilate the biliary tree; biliary atresia is a correctable ductal stenosis',\n        'Liver biopsy alone is sufficient to confirm biliary atresia and plan further management',\n        'Wait until 3 months of age; physiological jaundice can persist this long and surgery carries unacceptable risk'\n      ],\n      exp:   '<strong>Biliary atresia (BA)<\/strong> \u2014 obliterative cholangiopathy affecting the extrahepatic biliary tree; the most common cause of neonatal <strong>conjugated (direct) hyperbilirubinaemia<\/strong> and the leading indication for paediatric liver transplantation. <br><br><strong>Clinical pointers:<\/strong> conjugated jaundice + acholic stools + dark urine + normal-sized liver (early) + elevated GGT. Physiological jaundice is <em>unconjugated<\/em> \u2014 never acholic stools. <br><br><strong>Investigation sequence:<\/strong> USS (non-dilated ducts, absent\/small GB \u2192 suspicious) \u2192 HIDA scan (no tracer excretion into gut = obstruction) \u2192 <strong>intraoperative cholangiogram<\/strong> (gold standard \u2014 confirms obliteration of bile ducts). <br><br><strong>Treatment: Kasai hepatoportoenterostomy<\/strong> \u2014 the fibrous biliary remnant at the porta hepatis is excised and a Roux-en-Y loop of jejunum is anastomosed directly to the porta, bypassing the obliterated ducts. <br><br><strong>Timing is critical:<\/strong> best outcomes when performed <strong>before 60 days of age<\/strong> (bile flow restored in ~80%); after 90 days, success drops sharply. Even with successful Kasai, ~70\u201380% eventually require liver transplantation by adulthood due to progressive biliary cirrhosis. <br><br><strong>ERCP<\/strong> has no role in biliary atresia \u2014 the ducts are obliterated, not stenosed. <strong>Liver biopsy<\/strong> (bile duct proliferation, portal fibrosis) supports the diagnosis but is not the definitive test for surgical planning.',\n      imgId: null\n    },\n\n    {\n      id:    4,\n      tag:   'Hepatobiliary &mdash; Hydatid Cyst',\n      stem:  'A <strong>35-year-old shepherd<\/strong> from a rural sheep-farming community presents with a <strong>3-year history of slowly enlarging right upper quadrant swelling<\/strong> and occasional dull aching. There is no fever or jaundice. USS reveals a <strong>large (9 cm) cystic lesion in the right lobe of the liver with internal daughter cysts and a \"double-wall\" appearance<\/strong>. Serum Echinococcus IgG ELISA is strongly positive. CT confirms the cystic lesion with calcification of the wall. There is no biliary communication and the cyst appears intact. Which is the most appropriate management?',\n      correct: 'PAIR (Puncture, Aspiration, Injection of scolicidal agent, Re-aspiration) with albendazole cover; appropriate for Gharbi Type II cyst',\n      opts: [\n        'PAIR (Puncture, Aspiration, Injection of scolicidal agent, Re-aspiration) with albendazole cover; appropriate for Gharbi Type II cyst',\n        'Immediate open surgery with total pericystectomy; PAIR is absolutely contraindicated due to risk of anaphylaxis',\n        'Albendazole alone for 6 months; cyst will resolve completely with medical therapy in most cases',\n        'Percutaneous drainage without scolicidal agent is safe and avoids systemic drug toxicity'\n      ],\n      exp:   '<strong>Hydatid disease<\/strong> \u2014 caused by <em>Echinococcus granulosus<\/em>; the dog is the definitive host, sheep are intermediate hosts, humans are accidental hosts. Endemic in sheep-farming regions (Mediterranean, Middle East, Central Asia, India). <br><br><strong>USS findings:<\/strong> daughter cysts within the mother cyst (\"cyst within a cyst\" \/ rosette appearance), double-wall (pericyst), sand-like echoes (hydatid sand = scolices + hooklets). <br><br><strong>Gharbi Classification (WHO-IWGE):<\/strong> Type I = simple unilocular (active); Type II = multivesicular with daughter cysts (active); Type III = solid matrix pattern (transitional); Type IV = calcified wall (inactive\/dead); Type V = fully calcified (inactive). <br><br><strong>PAIR<\/strong> (Puncture, Aspiration, Injection of hypertonic saline 20% or ethanol as scolicidal, Re-aspiration) is the <strong>first-line interventional treatment<\/strong> for accessible, uncomplicated cysts (Gharbi I and II). Always given with <strong>albendazole<\/strong> (400 mg BD, 2 cycles peri-procedure) to prevent secondary seeding. Anaphylaxis risk with PAIR is low (&lt;1%) when performed correctly under steroid cover. <br><br><strong>Contraindications to PAIR:<\/strong> biliary communication, superficially located cysts (risk of peritoneal spillage), inaccessible cysts, Gharbi Type IV\/V (inactive \u2014 no treatment needed). <br><br><strong>Surgery (total pericystectomy or partial pericystectomy)<\/strong> is preferred for: large cysts (&gt;10 cm), infected cysts, biliary communication (presents as jaundice or cholangitis), failed PAIR, superficial cysts. Spillage during surgery causes secondary hydatidosis \u2014 field is packed with hypertonic saline-soaked swabs. <br><br><strong>Albendazole alone<\/strong> is not curative \u2014 reduces cyst viability but rarely eliminates it; used as adjunct.',\n      imgId: null\n    },\n\n    {\n      id:    5,\n      tag:   'Hepatobiliary &mdash; Carcinoma Pancreas',\n      stem:  'A <strong>65-year-old man<\/strong>, a smoker of 40 pack-years, presents with a <strong>6-week history of progressive painless jaundice, significant weight loss (7 kg), and pruritus<\/strong>. He also reports new-onset diabetes. On examination the <strong>gallbladder is palpably enlarged and non-tender<\/strong>. Bilirubin is 180 &mu;mol\/L; CA 19-9 is 840 U\/mL. CT abdomen shows a <strong>3 cm hypodense mass in the head of the pancreas<\/strong> causing dilatation of both the CBD and the main pancreatic duct. The SMA and coeliac axis are clear; no liver metastases. What is the most appropriate management?',\n      correct: 'Staging is resectable; proceed to Whipple\\'s pancreaticoduodenectomy with curative intent',\n      opts: [\n        'Staging is resectable; proceed to Whipple\\'s pancreaticoduodenectomy with curative intent',\n        'Palliative biliary stenting via ERCP is the only option; pancreatic head tumours are never resectable at this size',\n        'Neoadjuvant chemotherapy (FOLFIRINOX) must be given for 6 months before any surgical consideration',\n        'CA 19-9 &gt;800 U\/mL indicates systemic disease; biopsy and palliative chemotherapy are appropriate'\n      ],\n      exp:   '<strong>Carcinoma of the pancreatic head<\/strong> is the classic cause of <strong>painless obstructive jaundice<\/strong> in an older patient. Key features here: painless jaundice + weight loss + new-onset DM + <strong>Courvoisier\\'s sign<\/strong> (palpable, non-tender GB \u2014 malignant obstruction does not scar the GB wall, unlike chronic cholelithiasis) + <strong>double-duct sign<\/strong> (simultaneous CBD + pancreatic duct dilatation). <br><br><strong>Resectability criteria (this patient is resectable):<\/strong> <br>&bull; No distant metastases \u2713 <br>&bull; SMA and coeliac axis clear (no encasement) \u2713 <br>&bull; SMV\/portal vein patent \u2713 <br>&bull; Only ~15\u201320% of patients present with resectable disease \u2014 this patient is fortunate. <br><br><strong>Whipple\\'s (pancreaticoduodenectomy):<\/strong> en-bloc resection of pancreatic head + duodenum + CBD + gallbladder + distal stomach (pylorus-preserving variant increasingly used). Reconstruction: pancreaticojejunostomy + hepaticojejunostomy + gastrojejunostomy. <br><br><strong>CA 19-9<\/strong> is a tumour marker, not a staging tool \u2014 elevated CA 19-9 alone does not preclude surgery. It is used for monitoring recurrence post-operatively. <br><br><strong>Palliative options<\/strong> (unresectable \/ metastatic): biliary stent (ERCP or PTBD) for jaundice; surgical bypass (hepaticojejunostomy + gastrojejunostomy = \"double bypass\") if endoscopic stenting fails; gemcitabine \u00b1 nab-paclitaxel or FOLFIRINOX chemotherapy. <br><br><strong>MC complication post-Whipple\\'s:<\/strong> delayed gastric emptying. Dreaded complication: <strong>pancreatic fistula<\/strong> (pancreaticojejunal leak) \u2192 treated with drainage + octreotide; re-operation if severe.',\n      imgId: 'surg03-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(s)   { return byId(NS + '-' + s); }\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(v) {\n    var k, n = 0;\n    for (k in answers) { if (answers.hasOwnProperty(k) && answers[k] === v) n++; }\n    return n;\n  }\n\n  function buildPips() {\n    var cont = gid('pips'), i, q, wl, wp, l, p;\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        l  = document.createElement('div'); l.className = 'mr-pip-line'; l.id = NS + '-pl' + q.id;\n        wl.appendChild(l); cont.appendChild(wl);\n      }\n      wp = document.createElement('div'); wp.className = 'mr-pip-wrap';\n      p  = document.createElement('div'); p.className = 'mr-pip'; p.id = NS + '-pip' + q.id;\n      p.textContent = String(q.id);\n      wp.appendChild(p); cont.appendChild(wp);\n    }\n  }\n\n  function build() {\n    var cont, i, q, opts, card, top, num, meta, tag, stem,\n        rule, od, exp, lbl, txt, imgDiv, imgSrc, j, opt, ls, ts;\n    cont = gid('cases'); 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'); card.className = 'mr-case';\n      top  = document.createElement('div'); top.className  = 'mr-case-top';\n      num  = document.createElement('div'); num.className  = 'mr-num';\n      num.textContent = q.id < 10 ? 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