from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether, PageBreak
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY

OUTPUT = "/home/daytona/workspace/acute-abdomen-exam/Acute_Abdomen_ACS_Exam_Answers.pdf"

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    rightMargin=1.8*cm, leftMargin=1.8*cm,
    topMargin=2*cm, bottomMargin=2*cm
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle(
    'DocTitle',
    parent=styles['Title'],
    fontSize=18,
    textColor=colors.HexColor('#1a237e'),
    spaceAfter=4,
    spaceBefore=0,
    alignment=TA_CENTER,
    fontName='Helvetica-Bold'
)

subtitle_style = ParagraphStyle(
    'SubTitle',
    parent=styles['Normal'],
    fontSize=10,
    textColor=colors.HexColor('#37474f'),
    spaceAfter=12,
    alignment=TA_CENTER,
    fontName='Helvetica'
)

q_header_style = ParagraphStyle(
    'QuestionHeader',
    parent=styles['Normal'],
    fontSize=12,
    textColor=colors.white,
    fontName='Helvetica-Bold',
    leftIndent=6,
    rightIndent=6,
    spaceAfter=0,
    spaceBefore=0,
)

question_box_style = ParagraphStyle(
    'QuestionBox',
    parent=styles['Normal'],
    fontSize=10.5,
    textColor=colors.HexColor('#1a237e'),
    fontName='Helvetica-Bold',
    spaceAfter=6,
    spaceBefore=10,
    leftIndent=0,
)

section_style = ParagraphStyle(
    'SectionHead',
    parent=styles['Normal'],
    fontSize=10,
    textColor=colors.HexColor('#b71c1c'),
    fontName='Helvetica-Bold',
    spaceAfter=3,
    spaceBefore=8,
    leftIndent=0,
)

body_style = ParagraphStyle(
    'Body',
    parent=styles['Normal'],
    fontSize=9.5,
    textColor=colors.HexColor('#212121'),
    fontName='Helvetica',
    spaceAfter=3,
    spaceBefore=2,
    leftIndent=12,
    leading=14,
    alignment=TA_JUSTIFY,
)

bullet_style = ParagraphStyle(
    'Bullet',
    parent=styles['Normal'],
    fontSize=9.5,
    textColor=colors.HexColor('#212121'),
    fontName='Helvetica',
    spaceAfter=2,
    spaceBefore=1,
    leftIndent=20,
    bulletIndent=10,
    leading=13,
)

tip_style = ParagraphStyle(
    'Tip',
    parent=styles['Normal'],
    fontSize=9,
    textColor=colors.HexColor('#1b5e20'),
    fontName='Helvetica-BoldOblique',
    spaceAfter=4,
    spaceBefore=4,
    leftIndent=8,
    borderPad=4,
    backColor=colors.HexColor('#e8f5e9'),
)

def q_number_table(num, question_text):
    """Create a colored header box for each question."""
    data = [[Paragraph(f"Q{num}.  {question_text}", q_header_style)]]
    t = Table(data, colWidths=[doc.width])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), colors.HexColor('#1a237e')),
        ('TOPPADDING', (0,0), (-1,-1), 6),
        ('BOTTOMPADDING', (0,0), (-1,-1), 6),
        ('LEFTPADDING', (0,0), (-1,-1), 10),
        ('RIGHTPADDING', (0,0), (-1,-1), 8),
        ('ROUNDEDCORNERS', [4,4,4,4]),
    ]))
    return t

def sec(text):
    return Paragraph(text, section_style)

def body(text):
    return Paragraph(text, body_style)

def bullet(text):
    return Paragraph(f"• {text}", bullet_style)

def tip(text):
    return Paragraph(f"✎ Exam Tip: {text}", tip_style)

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=colors.HexColor('#bdbdbd'), spaceAfter=4, spaceBefore=4)

# ======================== CONTENT ========================

story = []

# ---- COVER ----
story.append(Spacer(1, 1.5*cm))
story.append(Paragraph("MS General Surgery Exam Preparation", title_style))
story.append(Paragraph("Acute Abdomen & Abdominal Compartment Syndrome", ParagraphStyle('sub2', parent=subtitle_style, fontSize=13, textColor=colors.HexColor('#1a237e'), fontName='Helvetica-Bold')))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("Based on Bailey & Love's Short Practice of Surgery, 28th Edition", subtitle_style))
story.append(Paragraph("Questions 142–148 | Structured Exam-Ready Answers | 15 minutes each", subtitle_style))
story.append(hr())
story.append(Spacer(1, 0.5*cm))

# =============================================
# Q142 - ACS: Definition, Pathophysiology, Evaluation, Management
# =============================================
story.append(q_number_table(142,
    "What is Abdominal Compartment Syndrome (ACS)? Discuss pathophysiology, evaluation and non-operative management strategies (2025). / Causes of development of ACS, physiological consequences, diagnosis and treatment (2022). / Define APP and ACS. Causes, risk factors and management of ACS (2023)."))
story.append(Spacer(1, 0.2*cm))

story.append(sec("DEFINITION"))
story.append(body("Abdominal Compartment Syndrome (ACS) is a sustained intra-abdominal pressure (IAP) >20 mmHg associated with new organ dysfunction/failure."))
story.append(body("Abdominal Perfusion Pressure (APP) = Mean Arterial Pressure (MAP) - IAP. Target APP >60 mmHg is associated with improved survival."))
story.append(body("Intra-abdominal Hypertension (IAH) = IAP >12 mmHg sustained. ACS = IAH + organ failure."))

story.append(sec("CLASSIFICATION"))
story.append(bullet("Primary ACS: due to abdominal/pelvic pathology (e.g. trauma, post-operative, pancreatitis, AAA rupture)"))
story.append(bullet("Secondary ACS: extra-abdominal causes - massive fluid resuscitation, burns, sepsis"))
story.append(bullet("Recurrent ACS: after surgical decompression"))

story.append(sec("CAUSES / RISK FACTORS"))
story.append(bullet("Increased intraluminal contents: ileus, bowel obstruction, colonic pseudo-obstruction"))
story.append(bullet("Increased intra-abdominal contents: haemoperitoneum, ascites, pneumoperitoneum, packing"))
story.append(bullet("Abdominal wall compliance decrease: major burns, tight closure after bowel oedema"))
story.append(bullet("Capillary leak/fluid resuscitation: >10L crystalloid, massive transfusion, damage control"))
story.append(bullet("Sepsis, pancreatitis, ruptured AAA, liver transplant, damage control surgery"))

story.append(sec("PATHOPHYSIOLOGY / PHYSIOLOGICAL CONSEQUENCES"))
table_data = [
    [Paragraph('<b>System</b>', styles['Normal']), Paragraph('<b>Effect of Raised IAP</b>', styles['Normal'])],
    ['Renal', 'Compression of renal vein/parenchyma → oliguria → ARF (most sensitive, occurs at IAP >15 mmHg)'],
    ['Cardiovascular', 'Reduced venous return (IVC compression) → ↓ CO; ↑ SVR; ↑ CVP/PCWP (falsely elevated)'],
    ['Respiratory', 'Diaphragm elevation → ↑ peak airway pressure, ↓ FRC, atelectasis, hypoxia, hypercarbia'],
    ['GIT', 'Mesenteric venous hypertension → gut ischaemia, mucosal barrier breakdown, bacterial translocation'],
    ['Hepatic', 'Portal/hepatic arterial compression → hepatic ischaemia, ↓ lactate clearance'],
    ['CNS', 'Raised ICP due to ↑ intrathoracic pressure impairing cerebral venous outflow'],
    ['Wound', 'Abdominal wall ischaemia → wound dehiscence, fascial necrosis'],
]
t = Table(table_data, colWidths=[3.5*cm, doc.width - 3.5*cm])
t.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a237e')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8.5),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#f5f5f5'), colors.white]),
    ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor('#9e9e9e')),
    ('TOPPADDING', (0,0), (-1,-1), 4),
    ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ('LEFTPADDING', (0,0), (-1,-1), 5),
    ('VALIGN', (0,0), (-1,-1), 'TOP'),
]))
story.append(t)
story.append(Spacer(1, 0.2*cm))

story.append(sec("EVALUATION / DIAGNOSIS"))
story.append(body("<b>IAP Measurement (Gold Standard):</b> Trans-vesical (bladder) pressure via urinary catheter with patient supine, end-expiration, zero at mid-axillary line. 25 mL saline instilled. Measured in mmHg (1 cmH₂O = 0.74 mmHg)."))
story.append(body("<b>Grading of IAH (WSACS):</b>"))
story.append(bullet("Grade I: IAP 12–15 mmHg"))
story.append(bullet("Grade II: IAP 16–20 mmHg"))
story.append(bullet("Grade III: IAP 21–25 mmHg"))
story.append(bullet("Grade IV: IAP >25 mmHg"))
story.append(body("<b>Clinical features:</b> Tense/distended abdomen, oliguria despite adequate resuscitation, raised peak airway pressures, haemodynamic instability. Confirmed by bladder pressure measurement."))

story.append(sec("NON-OPERATIVE MANAGEMENT STRATEGIES"))
story.append(body("Indicated for IAH (Grade I–II) without end-organ failure. Aim to reduce IAP:"))
story.append(bullet("Nasogastric decompression, rectal enemas, neostigmine for colonic pseudo-obstruction"))
story.append(bullet("Paracentesis/drainage of ascites or haematoma (image-guided)"))
story.append(bullet("Optimize fluid balance: avoid excessive crystalloids, use vasopressors to maintain MAP"))
story.append(bullet("Neuromuscular blockade reduces abdominal wall tension (short-term)"))
story.append(bullet("Body position: head of bed <30 degrees"))
story.append(bullet("Optimize sedation and analgesia"))
story.append(bullet("Diuresis/ultrafiltration if fluid overloaded"))
story.append(body("<b>Surgical decompression (Decompressive Laparotomy):</b> Indicated when IAP >20 mmHg + organ dysfunction failing non-operative measures. Open abdomen technique (laparostomy) with temporary abdominal closure."))
story.append(tip("Examiner favourite: APP = MAP - IAP; target APP >60 mmHg. Know the WSACS IAH grades. Bladder pressure is the diagnostic gold standard. Kidney is the most sensitive organ affected."))

story.append(Spacer(1, 0.3*cm))

# =============================================
# Q143 - ACS: Effects on individual organs, management of complications
# =============================================
story.append(PageBreak())
story.append(q_number_table(143,
    "What is ACS? Effects on individual organs. How do you manage the complications (2014)? Comment on grading of ACS. What is Intra-abdominal Hypertension (IAH) management algorithm?"))
story.append(Spacer(1, 0.2*cm))

story.append(sec("DEFINITION (brief)"))
story.append(body("ACS = sustained IAP >20 mmHg with new organ dysfunction. IAH = IAP >12 mmHg. APP = MAP - IAP."))

story.append(sec("EFFECTS ON INDIVIDUAL ORGANS"))
story.append(body("<b>1. RENAL (most sensitive):</b>"))
story.append(bullet("↑ IAP compresses renal cortex and veins → ↑ renal vascular resistance"))
story.append(bullet("↓ GFR and renal blood flow → oliguria at IAP >15 mmHg, anuria at >30 mmHg"))
story.append(bullet("Release of ADH and aldosterone compounds oliguria"))
story.append(bullet("Management: decompression restores urine output promptly; early haemofiltration if prolonged ARF"))

story.append(body("<b>2. CARDIOVASCULAR:</b>"))
story.append(bullet("IVC and portal vein compression → ↓ venous return → ↓ cardiac output"))
story.append(bullet("Diaphragm elevation → ↑ intrathoracic pressure → ↑ afterload"))
story.append(bullet("CVP and PCWP falsely elevated (do not reflect true preload)"))
story.append(bullet("Management: vasopressors (noradrenaline) to maintain APP >60 mmHg; avoid fluid overload"))

story.append(body("<b>3. RESPIRATORY:</b>"))
story.append(bullet("Diaphragm pushed cephalad → ↓ FRC, atelectasis, V/Q mismatch"))
story.append(bullet("↑ Peak airway pressures → barotrauma risk"))
story.append(bullet("Hypoxaemia, hypercarbia, respiratory acidosis"))
story.append(bullet("Management: permissive hypercapnia, low tidal volumes; decompression reduces airway pressures"))

story.append(body("<b>4. GASTROINTESTINAL:</b>"))
story.append(bullet("Mesenteric venous hypertension → gut wall oedema, mucosal ischaemia"))
story.append(bullet("Bacterial translocation → systemic sepsis, SIRS"))
story.append(bullet("Hepatic artery/portal vein compression → hepatic dysfunction, impaired lactate metabolism"))
story.append(bullet("Management: enteral feeding when possible; abdominal decompression"))

story.append(body("<b>5. CNS:</b>"))
story.append(bullet("↑ Intrathoracic pressure impairs cerebral venous drainage → ↑ ICP"))
story.append(bullet("↓ CPP (Cerebral Perfusion Pressure = MAP - ICP)"))
story.append(bullet("Relevant in patients with concurrent head injury"))

story.append(body("<b>6. ABDOMINAL WALL:</b>"))
story.append(bullet("Ischaemia of fascial layers → wound dehiscence, necrotising fasciitis risk"))

story.append(sec("GRADING OF ACS / IAH (WSACS Classification)"))
grade_data = [
    [Paragraph('<b>Grade</b>', styles['Normal']), Paragraph('<b>IAP (mmHg)</b>', styles['Normal']), Paragraph('<b>Action</b>', styles['Normal'])],
    ['I', '12–15', 'Medical management, close monitoring'],
    ['II', '16–20', 'Aggressive medical management'],
    ['III', '21–25', 'Decompressive laparotomy if organ dysfunction'],
    ['IV', '>25', 'Urgent decompressive laparotomy'],
]
gt = Table(grade_data, colWidths=[2.5*cm, 3.5*cm, doc.width - 6*cm])
gt.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#b71c1c')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8.5),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#fff3e0'), colors.white]),
    ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor('#9e9e9e')),
    ('ALIGN', (0,0), (-1,-1), 'CENTER'),
    ('VALIGN', (0,0), (-1,-1), 'MIDDLE'),
    ('TOPPADDING', (0,0), (-1,-1), 4),
    ('BOTTOMPADDING', (0,0), (-1,-1), 4),
]))
story.append(gt)
story.append(Spacer(1, 0.2*cm))

story.append(sec("IAH/ACS MANAGEMENT ALGORITHM"))
story.append(body("Step 1 - Measure IAP (trans-vesical) every 4 hours in at-risk ICU patients."))
story.append(body("Step 2 - If IAP >12 mmHg (IAH):"))
story.append(bullet("Evacuate intraluminal contents (NG tube, enema, colonoscopic decompression)"))
story.append(bullet("Evacuate intraperitoneal fluid/collections (ultrasound-guided percutaneous drainage)"))
story.append(bullet("Improve abdominal wall compliance (sedation, analgesia, neuromuscular blockade, positioning)"))
story.append(bullet("Optimize fluid resuscitation (MAP target, avoid excess crystalloid), diuretics/ultrafiltration"))
story.append(body("Step 3 - If IAP >20 mmHg + organ failure despite above:"))
story.append(bullet("SURGICAL DECOMPRESSION: midline laparotomy, open abdomen, temporary closure"))
story.append(body("Step 4 - Post-decompression: plan for delayed fascial closure (24–72 hours), use Bogota bag / Vac-Pac / ABTHERA system."))
story.append(tip("Key algorithm phrase: 'Serial bladder pressure monitoring → stepwise non-operative measures → decompressive laparotomy + open abdomen if failing.' Know APP = MAP - IAP; target >60 mmHg."))

story.append(Spacer(1, 0.3*cm))

# =============================================
# Q144 - Temporary Closure of Abdominal Cavity
# =============================================
story.append(PageBreak())
story.append(q_number_table(144, "Temporary Closure of the Abdominal Cavity"))
story.append(Spacer(1, 0.2*cm))

story.append(sec("DEFINITION & INDICATIONS"))
story.append(body("Temporary abdominal closure (TAC) = intentional non-closure of the fascial/skin layers after laparotomy, with protection of abdominal contents. Used when formal closure is unsafe or impossible."))
story.append(body("<b>Indications (ABCDE mnemonic):</b>"))
story.append(bullet("A - ACS or prevention of ACS after damage control surgery"))
story.append(bullet("B - Bowel oedema - unable to close without undue tension"))
story.append(bullet("C - Contamination severe (faecal peritonitis) - planned re-look"))
story.append(bullet("D - Damage control surgery (haemorrhage control phase)"))
story.append(bullet("E - Enterocutaneous fistula management / staged closure after staged procedures"))

story.append(sec("TECHNIQUES OF TEMPORARY CLOSURE"))
story.append(body("<b>1. Towel clip / Skin-only closure:</b> Rapid, emergency use only. Fascia left open, skin approximated with towel clips. Risk of ACS if fascia is closed tightly."))

story.append(body("<b>2. Bogota Bag (Silo closure):</b>"))
story.append(bullet("Sterile 3-litre IV fluid bag or silastic sheet sutured to skin edges"))
story.append(bullet("Protects bowel, allows inspection, accommodates oedema"))
story.append(bullet("Simple, inexpensive, widely available"))

story.append(body("<b>3. Vac-Pac / OPSITE Sandwich (Bailey &amp; Love):</b>"))
story.append(bullet("Fenestrated plastic sheet placed over bowel (non-adherent layer)"))
story.append(bullet("Surgical towels/swabs placed as intermediate absorptive layer"))
story.append(bullet("OPSITE® or similar adherent plastic drape covers entire construct"))
story.append(bullet("Suction drains applied to collect abdominal fluid"))
story.append(bullet("Creates watertight, airtight seal; easy to change"))

story.append(body("<b>4. Negative Pressure Wound Therapy (NPWT) - ABTHERA / KCI system:</b>"))
story.append(bullet("Commercial device with polyurethane foam tracks placed in paracolic gutters"))
story.append(bullet("Continuous negative pressure (-75 to -125 mmHg)"))
story.append(bullet("Reduces wound fluid, maintains fascial domain, may aid fascial closure"))
story.append(bullet("Preferred current standard in most centres"))

story.append(body("<b>5. Wittmann Patch (zipper):</b>"))
story.append(bullet("Velcro-like device sutured to fascial edges"))
story.append(bullet("Allows progressive fascial approximation at each re-look"))
story.append(bullet("Facilitates planned delayed primary fascial closure"))

story.append(body("<b>6. Mesh-based closure (Absorbable/Non-absorbable):</b>"))
story.append(bullet("Synthetic absorbable mesh (polyglycolic acid) sutured to fascial edges"))
story.append(bullet("Used when fascial closure not achievable; allows eventual skin grafting"))

story.append(sec("PRINCIPLES OF MANAGEMENT"))
story.append(bullet("Re-look laparotomy at 24–72 hours for definitive repair once physiology normalised"))
story.append(bullet("Aim for primary fascial closure within 7 days if possible (reduces incisional hernia)"))
story.append(bullet("Enteral nutrition maintained via jejunal feeding"))
story.append(bullet("Measure IAP after each closure attempt"))
story.append(bullet("Vacuum-assisted dressings (Vac-Pac) reduce fluid output and facilitate closure"))

story.append(sec("COMPLICATIONS"))
story.append(bullet("Enterocutaneous fistula (most feared) - especially with mesh"))
story.append(bullet("Loss of abdominal domain → planned ventral hernia"))
story.append(bullet("Wound infection, desiccation of bowel"))
story.append(bullet("Fluid/protein loss from open abdomen"))
story.append(tip("Know the OPSITE/Vac-Pac technique in detail (Bailey & Love). Mention NPWT as current preferred. State goal: definitive fascial closure within 7 days. Fistula = most feared complication."))

story.append(Spacer(1, 0.3*cm))

# =============================================
# Q145 - Management of Patients with Open Abdomen (2015)
# =============================================
story.append(PageBreak())
story.append(q_number_table(145, "Management of Patients with Open Abdomen (2015)"))
story.append(Spacer(1, 0.2*cm))

story.append(sec("DEFINITION"))
story.append(body("Open abdomen (laparostomy) = abdominal fascia intentionally left open after surgery, with temporary closure of the wound. The bowel and viscera remain exposed/covered only by dressing."))

story.append(sec("INDICATIONS"))
story.append(bullet("Damage control surgery (haemorrhage + contamination control)"))
story.append(bullet("ACS / prevention of ACS"))
story.append(bullet("Severe peritonitis requiring planned re-look"))
story.append(bullet("Inability to close fascia (oedematous bowel, mesenteric retraction)"))
story.append(bullet("Secondary ACS after massive resuscitation"))

story.append(sec("CLASSIFICATION (Bjorck 2009)"))
story.append(body("1A: Clean, no adherence | 1B: Contaminated, no adherence | 2A: Developing fixity (clean) | 2B: Developing fixity (contaminated) | 3: Enteroatmospheric fistula | 4: Frozen abdomen (failed closure)"))

story.append(sec("MANAGEMENT STRATEGY"))
story.append(body("<b>ICU Phase (Phase 1 - Resuscitation):</b>"))
story.append(bullet("Correct hypothermia, coagulopathy, acidosis ('lethal triad')"))
story.append(bullet("Target: Temperature >36°C, pH >7.35, INR <1.5, lactate <2 mmol/L"))
story.append(bullet("Damage control resuscitation: 1:1:1 ratio (PRBC:FFP:Platelets), avoid excess crystalloid"))
story.append(bullet("Vasopressors to maintain MAP >65 mmHg, APP >60 mmHg"))
story.append(bullet("Mechanical ventilation with lung-protective strategy"))
story.append(bullet("Enteral feeding via nasojejunal tube if bowel function permits"))
story.append(bullet("IAP monitoring every 4 hours"))

story.append(body("<b>Temporary Closure Care:</b>"))
story.append(bullet("NPWT (ABTHERA system) preferred: protects bowel, reduces fluid loss, aids closure"))
story.append(bullet("Daily dressing changes if needed; avoid desiccation of bowel"))
story.append(bullet("Measure wound output and replace losses (protein-rich fluid loss can be >2 L/day)"))

story.append(body("<b>Planned Re-look Laparotomy (Phase 2 - Reassessment at 24-72 hours):</b>"))
story.append(bullet("Wash-out of peritoneal cavity"))
story.append(bullet("Reassess bowel viability; perform anastomosis if safe"))
story.append(bullet("Attempt progressive fascial closure at each sitting"))
story.append(bullet("Repeat until definitive closure achieved or planned hernia (Wittmann patch/serial closure)"))

story.append(body("<b>Definitive Closure (Phase 3):</b>"))
story.append(bullet("Primary fascial closure: aim within 7 days"))
story.append(bullet("Component separation if needed for tension-free closure"))
story.append(bullet("If closure fails → skin graft over granulating bowel → delayed reconstruction"))

story.append(sec("COMPLICATIONS"))
story.append(bullet("Enteroatmospheric (enterocutaneous) fistula - 10-25% incidence"))
story.append(bullet("Wound infection, bacteraemia"))
story.append(bullet("Fluid and protein loss, malnutrition"))
story.append(bullet("Loss of abdominal domain → planned ventral hernia"))
story.append(bullet("Adhesion-related bowel obstruction"))
story.append(tip("Key phrase: 'Damage control resuscitation runs concurrently with damage control surgery.' Primary fascial closure within 7 days is the goal. NPWT is current gold standard for temporary closure."))

story.append(Spacer(1, 0.3*cm))

# =============================================
# Q146 - Management of Burst Abdomen (2006)
# =============================================
story.append(PageBreak())
story.append(q_number_table(146, "Management of Burst Abdomen (Wound Dehiscence / Abdominal Wound Dehiscence) (2006)"))
story.append(Spacer(1, 0.2*cm))

story.append(sec("DEFINITION"))
story.append(body("Burst abdomen (abdominal wound dehiscence / evisceration) = disruption of all layers of an abdominal wound with protrusion of abdominal contents. Occurs within 7–10 days post-operatively."))

story.append(sec("INCIDENCE & RISK FACTORS"))
story.append(body("Incidence: ~1–3% of abdominal surgeries. Mortality: 10–30% (mainly from underlying sepsis)."))
story.append(body("<b>Risk Factors (remember ABCDE):</b>"))
story.append(bullet("A - Age (elderly), Albumin low (malnutrition, hypoalbuminaemia <30 g/L)"))
story.append(bullet("B - BMI (obesity, cachexia), Bowel disease (IBD, malignancy)"))
story.append(bullet("C - Corticosteroids, Chemotherapy, Coughing (raised intra-abdominal pressure)"))
story.append(bullet("D - Diabetes mellitus, Drug-induced immunosuppression"))
story.append(bullet("E - Emergency surgery, Extensive contamination (peritonitis), anaemia"))
story.append(bullet("Technical: poor closure technique, mass closure failures, dead space, haematoma, wound infection"))

story.append(sec("CLINICAL FEATURES"))
story.append(bullet("'Pink fluid' (serosanguineous) discharge from wound on day 5-8 = PATHOGNOMONIC sign"))
story.append(bullet("Visible loops of bowel through wound"))
story.append(bullet("Swelling and gaping of wound"))
story.append(bullet("Patient may report 'something giving way'"))

story.append(sec("PREVENTION"))
story.append(bullet("Mass closure (Jenkins rule): suture length to wound length ratio >4:1"))
story.append(bullet("Looped nylon / PDS No.1 for closure"))
story.append(bullet("Retention sutures in high-risk patients"))
story.append(bullet("Correct malnutrition pre-operatively"))
story.append(bullet("Prophylactic antibiotics, glycaemic control"))

story.append(sec("MANAGEMENT"))
story.append(body("<b>Immediate (Emergency) Management:</b>"))
story.append(bullet("Reassure patient; lay supine"))
story.append(bullet("Cover eviscerated bowel with warm, moist sterile saline packs"))
story.append(bullet("Do NOT attempt to return bowel at ward level"))
story.append(bullet("IV access, fluid resuscitation, NBM"))
story.append(bullet("Analgesia, broad-spectrum antibiotics"))
story.append(bullet("Urgent return to operating theatre"))

story.append(body("<b>Surgical Management:</b>"))
story.append(bullet("Examine bowel viability, reduce contents, lavage"))
story.append(bullet("Re-suture: mass closure with interrupted No.1 nylon (tension sutures) or PDS loop"))
story.append(bullet("'Retention sutures' through all layers placed 2–3 cm from wound edge and 2–3 cm apart"))
story.append(bullet("Retention sutures tied over plastic or rubber tubing ('bolsters') to prevent cutting"))
story.append(bullet("Remove at 3 weeks"))
story.append(bullet("If contaminated: leave skin open (delayed primary closure)"))

story.append(sec("COMPLICATIONS"))
story.append(bullet("Incisional hernia (most common late complication ~30–50%)"))
story.append(bullet("Wound infection, sepsis"))
story.append(bullet("Enterocutaneous fistula"))
story.append(bullet("Recurrent dehiscence"))
story.append(tip("Classic exam question: Pink serosanguineous discharge on day 5-8 = pathognomonic of impending burst. Jenkins rule for closure. Retention sutures over bolsters. Incisional hernia = most common sequel."))

story.append(Spacer(1, 0.3*cm))

# =============================================
# Q147 - Laparoscopic Management of Acute Abdomen (2010)
# =============================================
story.append(PageBreak())
story.append(q_number_table(147, "Discuss Laparoscopic Management of Acute Abdomen (2010)"))
story.append(Spacer(1, 0.2*cm))

story.append(sec("INTRODUCTION"))
story.append(body("Laparoscopy has transformed the management of the acute abdomen, providing both diagnostic and therapeutic advantages. The 'diagnostic laparoscopy' converts to therapeutic in >50% of cases, avoiding unnecessary laparotomy."))

story.append(sec("ADVANTAGES OF LAPAROSCOPY IN ACUTE ABDOMEN"))
story.append(bullet("Diagnostic accuracy: directly visualizes entire peritoneal cavity"))
story.append(bullet("Reduced wound complications: smaller incisions, less surgical site infection"))
story.append(bullet("Faster recovery, shorter hospital stay, earlier return to work"))
story.append(bullet("Less post-operative pain, reduced ileus"))
story.append(bullet("Better cosmesis"))
story.append(bullet("Can avoid unnecessary laparotomy in 'negative' explorations"))

story.append(sec("SPECIFIC CONDITIONS AND LAPAROSCOPIC MANAGEMENT"))

lapa_data = [
    [Paragraph('<b>Condition</b>', styles['Normal']), Paragraph('<b>Laparoscopic Approach</b>', styles['Normal']), Paragraph('<b>Notes</b>', styles['Normal'])],
    ['Acute Appendicitis', 'Laparoscopic appendicectomy (3-port)', 'Gold standard; advantages in obese, women of childbearing age, diagnostic uncertainty'],
    ['Perforated Peptic Ulcer', 'Laparoscopic Graham patch repair', 'Equivalent outcomes to open; reduced morbidity; need for washout'],
    ['Acute Cholecystitis', 'Laparoscopic cholecystectomy (within 72 hrs)', 'Early lap cholecystectomy preferred; subtotal if severe inflammation'],
    ['Adhesional Bowel Obstruction', 'Laparoscopic adhesiolysis', 'Select cases (single band, early presentation, no strangulation); conversion if needed'],
    ['Sigmoid Volvulus', 'Diagnostic ± mesosigmoidoplasty / sigmoid resection', 'After initial colonoscopic decompression failure'],
    ['Gynaecological (ectopic, torsion)', 'Salpingectomy, de-torsion, cystectomy', 'Diagnostic and therapeutic in same setting'],
    ['Mesenteric Ischaemia', 'Diagnostic laparoscopy only (bowel assessment)', 'Limited role; laparotomy if resection needed'],
    ['Abdominal Trauma', 'Haemoperitoneum assessment, solid organ injury', 'Limited role; unstable patients → laparotomy'],
]
lt = Table(lapa_data, colWidths=[3.5*cm, 5*cm, doc.width - 8.5*cm])
lt.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#1a237e')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#e8eaf6'), colors.white]),
    ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor('#9e9e9e')),
    ('TOPPADDING', (0,0), (-1,-1), 4),
    ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ('LEFTPADDING', (0,0), (-1,-1), 4),
    ('VALIGN', (0,0), (-1,-1), 'TOP'),
]))
story.append(lt)
story.append(Spacer(1, 0.2*cm))

story.append(sec("CONTRAINDICATIONS TO LAPAROSCOPY IN ACUTE ABDOMEN"))
story.append(bullet("Haemodynamic instability (relative) → proceed to open"))
story.append(bullet("Suspected bowel obstruction with significantly distended loops (↑ perforation risk with trocar)"))
story.append(bullet("Previous extensive abdominal surgery with dense adhesions"))
story.append(bullet("Inability to tolerate pneumoperitoneum (severe cardiorespiratory disease)"))
story.append(bullet("Known intra-abdominal malignancy (port-site metastasis risk)"))

story.append(sec("TECHNIQUE CONSIDERATIONS"))
story.append(bullet("Entry: open (Hasson) technique preferred in acute abdomen (obliterated umbilicus or distension)"))
story.append(bullet("CO₂ insufflation pressure: 12–15 mmHg; monitor for adverse effects on physiology"))
story.append(bullet("Exploratory sequence: systematic inspection from right upper to left upper, then pelvis"))
story.append(bullet("Peritoneal lavage: with warm saline for peritonitis"))
story.append(bullet("Conversion: low threshold; not a failure"))

story.append(sec("LIMITATIONS"))
story.append(bullet("Learning curve; requires general anaesthesia"))
story.append(bullet("CO₂ pneumoperitoneum: diaphragmatic splinting, raised CVP, hypercarbia"))
story.append(bullet("Difficult in grossly distended abdomen"))
story.append(tip("State that laparoscopy is diagnostic AND therapeutic. For the exam: list 4–5 specific conditions. Mention Graham patch repair for PU, 3-port appendicectomy, and early lap cholecystectomy. Always mention conversion is not a failure."))

story.append(Spacer(1, 0.3*cm))

# =============================================
# Q148 - Principles of USG Imaging in Acute Abdomen
# =============================================
story.append(PageBreak())
story.append(q_number_table(148, "Principles of USG Imaging and Its Role in the Acute Abdomen"))
story.append(Spacer(1, 0.2*cm))

story.append(sec("INTRODUCTION"))
story.append(body("Ultrasound (USG) is a first-line, rapid, radiation-free, bedside-available imaging modality in the acute abdomen. It is operator-dependent but invaluable in the emergency setting."))

story.append(sec("PRINCIPLES OF ULTRASOUND"))
story.append(bullet("Uses high-frequency sound waves (2–15 MHz) reflected from tissue interfaces"))
story.append(bullet("Real-time, dynamic imaging; Doppler for vascular assessment"))
story.append(bullet("No ionising radiation; safe in pregnancy"))
story.append(bullet("Excellent for fluid, gallstones, solid organ assessment"))
story.append(bullet("Limited by: obesity, bowel gas, operator skill"))

story.append(sec("ROLE IN SPECIFIC CONDITIONS"))

usg_data = [
    [Paragraph('<b>Condition</b>', styles['Normal']), Paragraph('<b>USG Findings</b>', styles['Normal']), Paragraph('<b>Sensitivity</b>', styles['Normal'])],
    ['Acute Cholecystitis', 'Gallstones (acoustic shadow), thick wall >4mm, pericholecystic fluid, Murphy\'s sign under probe', '88-94%'],
    ['Free Fluid (FAST)', 'Fluid in Morison\'s pouch, splenorenal recess, pelvis (Douglas pouch)', 'Detects >250 mL'],
    ['AAA', 'Aortic diameter >3 cm; retroperitoneal haematoma', '99% for AAA diameter'],
    ['Bowel Obstruction', 'Dilated fluid-filled loops, to-and-fro peristalsis, transition point', 'Moderate'],
    ['Appendicitis', 'Non-compressible, aperistaltic tube >6mm, periappendiceal fat oedema', '75-85%'],
    ['Intussusception', 'Target sign (concentric rings in cross-section)', 'High in children'],
    ['Ectopic Pregnancy', 'Empty uterus, adnexal mass, free pelvic fluid, absent intrauterine sac', 'Depends on gestation'],
    ['Hepatic/Splenic Injury', 'Laceration echogenicity, haematoma, free fluid', 'FAST-positive'],
    ['Ovarian/Adnexal Torsion', 'Enlarged ovary, whirlpool sign on Doppler, absent flow', '85-90%'],
    ['Renal Colic', 'Hydronephrosis, ureteric stone', 'Good for hydronephrosis'],
]
ut = Table(usg_data, colWidths=[3.8*cm, doc.width - 7*cm, 2.8*cm])
ut.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,0), colors.HexColor('#006064')),
    ('TEXTCOLOR', (0,0), (-1,0), colors.white),
    ('FONTNAME', (0,0), (-1,0), 'Helvetica-Bold'),
    ('FONTSIZE', (0,0), (-1,-1), 8),
    ('ROWBACKGROUNDS', (0,1), (-1,-1), [colors.HexColor('#e0f7fa'), colors.white]),
    ('GRID', (0,0), (-1,-1), 0.4, colors.HexColor('#9e9e9e')),
    ('TOPPADDING', (0,0), (-1,-1), 4),
    ('BOTTOMPADDING', (0,0), (-1,-1), 4),
    ('LEFTPADDING', (0,0), (-1,-1), 4),
    ('VALIGN', (0,0), (-1,-1), 'TOP'),
]))
story.append(ut)
story.append(Spacer(1, 0.2*cm))

story.append(sec("FAST SCAN (Focused Assessment with Sonography in Trauma)"))
story.append(body("Protocol for rapid assessment of free fluid in trauma:"))
story.append(bullet("4 windows: Pericardial (subxiphoid), Right upper quadrant (Morison's pouch - hepatorenal), Left upper quadrant (splenorenal recess), Suprapubic (pelvic free fluid / Douglas pouch)"))
story.append(bullet("E-FAST adds bilateral thorax windows for pneumothorax/haemothorax"))
story.append(bullet("Takes <3 minutes; performed in A&E resuscitation room"))
story.append(bullet("Positive = free fluid detected → guide to laparotomy in unstable patients"))

story.append(sec("LIMITATIONS OF USG IN ACUTE ABDOMEN"))
story.append(bullet("Operator-dependent skill required"))
story.append(bullet("Bowel gas obscures retroperitoneum, pancreas, aorta (in obese patients)"))
story.append(bullet("Poor for CT-detected pathologies (mesenteric ischaemia, retroperitoneal injury)"))
story.append(bullet("Limited for hollow organ perforation (pneumoperitoneum better on erect CXR or CT)"))

story.append(sec("OTHER IMAGING MODALITIES IN ACUTE ABDOMEN"))
story.append(bullet("Plain X-ray (AXR/erect CXR): free air under diaphragm (perforation), Rigler's sign, Sentinel loop, pneumatosis intestinalis"))
story.append(bullet("CT abdomen/pelvis with contrast: gold standard for diagnosis in acute abdomen (highest sensitivity and specificity for most conditions)"))
story.append(bullet("MRI: pregnant patients, appendicitis (second line to CT)"))
story.append(bullet("Contrast studies (Gastrograffin swallow): anastomotic leak, esophageal perforation"))
story.append(bullet("Angiography/CT angiography: mesenteric ischaemia, GI bleeding"))
story.append(tip("For the exam: FAST scan windows (4 + E-FAST). USG is first-line, CT is gold standard. Mention advantages (no radiation, bedside, real-time Doppler) and limitations (operator-dependent, bowel gas)."))

story.append(Spacer(1, 0.4*cm))
story.append(hr())

# Footer reference
story.append(Paragraph(
    "Source: Bailey and Love's Short Practice of Surgery, 28th Edition. "
    "All answers structured for 15-minute exam responses covering key scoring points.",
    ParagraphStyle('Footer', parent=styles['Normal'], fontSize=8, textColor=colors.HexColor('#757575'),
                   alignment=TA_CENTER, fontName='Helvetica-Oblique')
))

# BUILD
doc.build(story)
print(f"PDF generated: {OUTPUT}")