Pyogenic Liver Abscess — Surgical Notes

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

OUTPUT = "/home/daytona/workspace/pyogenic-liver-abscess/Pyogenic_Liver_Abscess_Notes.pdf"

# Colors
DARK_BLUE   = HexColor("#1a3a5c")
MED_BLUE    = HexColor("#2563a8")
LIGHT_BLUE  = HexColor("#dbeafe")
ACCENT_GOLD = HexColor("#b45309")
TABLE_HEADER= HexColor("#1e3a5f")
TABLE_ALT   = HexColor("#f0f5ff")
BORDER_BLUE = HexColor("#3b82f6")
RED         = HexColor("#b91c1c")
GREEN       = HexColor("#166534")
LIGHT_GREY  = HexColor("#f8fafc")

doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=2*cm, rightMargin=2*cm,
    topMargin=2.5*cm, bottomMargin=2.5*cm,
    title="Pyogenic Liver Abscess — Surgical Notes",
    author="Orris Medical"
)

styles = getSampleStyleSheet()

# Custom styles
title_style = ParagraphStyle("Title", parent=styles["Normal"],
    fontSize=22, textColor=white, fontName="Helvetica-Bold",
    alignment=TA_CENTER, spaceAfter=4)

subtitle_style = ParagraphStyle("Subtitle", parent=styles["Normal"],
    fontSize=11, textColor=HexColor("#cfe0ff"), fontName="Helvetica",
    alignment=TA_CENTER, spaceAfter=2)

h1_style = ParagraphStyle("H1", parent=styles["Normal"],
    fontSize=13, textColor=white, fontName="Helvetica-Bold",
    spaceBefore=10, spaceAfter=4, leftIndent=0,
    backColor=DARK_BLUE, borderPad=6)

h2_style = ParagraphStyle("H2", parent=styles["Normal"],
    fontSize=11, textColor=DARK_BLUE, fontName="Helvetica-Bold",
    spaceBefore=8, spaceAfter=3, leftIndent=0,
    borderPad=2)

body_style = ParagraphStyle("Body", parent=styles["Normal"],
    fontSize=9.5, textColor=HexColor("#1e293b"), fontName="Helvetica",
    leading=14, spaceAfter=4, alignment=TA_JUSTIFY)

bullet_style = ParagraphStyle("Bullet", parent=styles["Normal"],
    fontSize=9.5, textColor=HexColor("#1e293b"), fontName="Helvetica",
    leading=13, spaceAfter=2, leftIndent=14, bulletIndent=4)

note_style = ParagraphStyle("Note", parent=styles["Normal"],
    fontSize=9, textColor=HexColor("#7c3aed"), fontName="Helvetica-Oblique",
    leading=13, spaceAfter=4, leftIndent=10)

key_style = ParagraphStyle("Key", parent=styles["Normal"],
    fontSize=9.5, textColor=HexColor("#166534"), fontName="Helvetica-Bold",
    leading=13, spaceAfter=3, leftIndent=14, bulletIndent=4,
    backColor=HexColor("#f0fdf4"), borderPad=4)

source_style = ParagraphStyle("Source", parent=styles["Normal"],
    fontSize=8, textColor=HexColor("#64748b"), fontName="Helvetica-Oblique",
    alignment=TA_CENTER, spaceBefore=6)


def section_header(text):
    """Blue banner heading."""
    tbl = Table([[Paragraph(f"  {text}", ParagraphStyle("H1inner",
        fontSize=12, textColor=white, fontName="Helvetica-Bold",
        leading=16, leftIndent=4))]],
        colWidths=[17*cm])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
        ("ROUNDEDCORNERS", [4]),
        ("TOPPADDING", (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
    ]))
    return tbl

def sub_header(text):
    return Paragraph(f'<font color="#2563a8"><b>▶ {text}</b></font>', h2_style)

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

def key_point(num, text):
    return Paragraph(f"<b>{num}.</b> {text}", key_style)

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

def note(text):
    return Paragraph(f"<i>{text}</i>", note_style)

def spacer(h=0.25):
    return Spacer(1, h*cm)

def hr():
    return HRFlowable(width="100%", thickness=0.5, color=BORDER_BLUE, spaceAfter=4, spaceBefore=4)


# ── TABLES ──────────────────────────────────────────────────────────────────

def make_table(headers, rows, col_widths=None):
    data = [[Paragraph(f"<b><font color='white'>{h}</font></b>",
                ParagraphStyle("TH", fontSize=9, fontName="Helvetica-Bold",
                    alignment=TA_CENTER, leading=12)) for h in headers]]
    for i, row in enumerate(rows):
        data.append([Paragraph(str(c),
            ParagraphStyle("TD", fontSize=9, fontName="Helvetica",
                leading=12, spaceAfter=1)) for c in row])
    if col_widths is None:
        col_widths = [17*cm / len(headers)] * len(headers)
    t = Table(data, colWidths=col_widths, repeatRows=1)
    style = [
        ("BACKGROUND", (0,0), (-1,0), TABLE_HEADER),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [white, TABLE_ALT]),
        ("GRID", (0,0), (-1,-1), 0.4, HexColor("#93c5fd")),
        ("TOPPADDING", (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING", (0,0), (-1,-1), 5),
        ("VALIGN", (0,0), (-1,-1), "TOP"),
        ("FONTSIZE", (0,0), (-1,-1), 9),
    ]
    t.setStyle(TableStyle(style))
    return t

# ── TITLE BLOCK ─────────────────────────────────────────────────────────────

def title_block():
    tbl = Table(
        [[Paragraph("PYOGENIC LIVER ABSCESS", title_style)],
         [Paragraph("Comprehensive Surgical Notes", subtitle_style)],
         [Paragraph("Sabiston · Mulholland & Greenfield · Sleisenger & Fordtran", subtitle_style)]],
        colWidths=[17*cm])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), DARK_BLUE),
        ("TOPPADDING", (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("ROUNDEDCORNERS", [6]),
    ]))
    return tbl


# ═══════════════════════════════════════════════════════════════════════════
#  BUILD STORY
# ═══════════════════════════════════════════════════════════════════════════
story = []

# Title
story.append(title_block())
story.append(spacer(0.5))

# Definition
story.append(section_header("1.  DEFINITION"))
story.append(spacer(0.2))
story.append(body(
    "A <b>pyogenic liver abscess (PLA)</b> is a focal collection of purulent bacterial material and "
    "necroinflammatory debris within the liver parenchyma. It may be <b>solitary or multiple</b> "
    "and is caused by one or more aerobic or anaerobic bacteria."
))

# Epidemiology
story.append(spacer(0.3))
story.append(section_header("2.  EPIDEMIOLOGY"))
story.append(spacer(0.2))
epi = [
    ("Annual incidence", "~2.3 cases per 100,000 persons"),
    ("Prevalence", "Most common type of visceral abscess (13% of intra-abdominal abscesses)"),
    ("Age shift", "Historically 20–30s (appendicitis era) → now predominantly <b>50–60s</b> (biliary/cryptogenic era)"),
    ("Sex ratio", "Male : Female ≈ <b>1.5 : 1</b>; no significant ethnic/geographic difference"),
    ("Lobe", "<b>Right lobe ~75%</b> of cases (greater portal venous flow)"),
    ("Key comorbidities", "Cirrhosis, diabetes mellitus, chronic renal failure, malignancy"),
]
t = Table(
    [[Paragraph(f"<b>{k}</b>", ParagraphStyle("EK", fontSize=9, fontName="Helvetica-Bold", leading=12)),
      Paragraph(v, ParagraphStyle("EV", fontSize=9, fontName="Helvetica", leading=12))] for k, v in epi],
    colWidths=[4.5*cm, 12.5*cm]
)
t.setStyle(TableStyle([
    ("ROWBACKGROUNDS", (0,0), (-1,-1), [LIGHT_BLUE, white]),
    ("GRID", (0,0), (-1,-1), 0.4, BORDER_BLUE),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 6),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(t)

# Aetiology
story.append(spacer(0.3))
story.append(section_header("3.  AETIOLOGY & ROUTES OF INFECTION"))
story.append(spacer(0.2))
ae_headers = ["Route", "Mechanism", "Common Causes"]
ae_rows = [
    ["Biliary tree\n(most common identifiable)", "Ascending suppurative cholangitis → bile stasis → bacterial colonisation",
     "Choledocholithiasis, malignant biliary obstruction, Caroli disease, biliary-enteric anastomosis, biliary ascariasis"],
    ["Portal vein (Pylephlebitis)", "Intra-abdominal infection → portal vein bacteraemia ascending to liver",
     "Appendicitis, diverticulitis, pancreatitis, IBD, PID, perforated viscus, omphalitis (neonates)"],
    ["Hepatic artery (systemic bacteraemia)", "Any systemic infection seeds liver via hepatic artery",
     "Endocarditis, pneumonia, osteomyelitis, septicaemia"],
    ["Direct extension", "Contiguous spread from adjacent infection",
     "Suppurative cholecystitis, subphrenic/perinephric abscess, bowel perforation into liver"],
    ["Trauma / iatrogenic", "Intrahepatic haematoma / necrosis → superinfection",
     "Penetrating/blunt trauma, hepatic artery embolisation, thermal ablation (especially with prior biliary-enteric anastomosis)"],
    ["Cryptogenic (most common overall)", "No identifiable source (~40% of cases)",
     "Possible: oral flora / severe periodontal disease (especially alcoholics); undetected GI malignancy"],
]
story.append(make_table(ae_headers, ae_rows, [3.5*cm, 5.5*cm, 8*cm]))
story.append(spacer(0.2))
story.append(note(
    "Historical note: Ochsner & DeBakey (1938) — appendicitis via portal vein was the dominant cause. "
    "Today, biliary disease and cryptogenic causes predominate in Western countries. "
    "In Asia, recurrent pyogenic cholangitis (intrahepatic stones) remains important."
))

# Risk Factors
story.append(spacer(0.3))
story.append(section_header("4.  RISK FACTORS"))
story.append(spacer(0.2))
rf_left = [
    "Diabetes mellitus (most important comorbidity)",
    "Cirrhosis",
    "Chronic renal failure",
    "Malignancy / immunosuppression",
    "Liver transplantation",
]
rf_right = [
    "Previous hepatobiliary/pancreatic disease or surgery",
    "Chronic granulomatous disease (children — susceptibility to S. aureus)",
    "Atrophic gastritis / elderly (altered bowel flora)",
    "Colorectal cancer: <b>fourfold increased incidence</b> of GI malignancy in PLA patients (especially Klebsiella pneumoniae)",
]
rf_data = []
for i in range(max(len(rf_left), len(rf_right))):
    l = bullet(rf_left[i]) if i < len(rf_left) else Paragraph("", body_style)
    r = bullet(rf_right[i]) if i < len(rf_right) else Paragraph("", body_style)
    rf_data.append([l, r])
rf_table = Table(rf_data, colWidths=[8.5*cm, 8.5*cm])
rf_table.setStyle(TableStyle([
    ("VALIGN", (0,0), (-1,-1), "TOP"),
    ("TOPPADDING", (0,0), (-1,-1), 2),
    ("BOTTOMPADDING", (0,0), (-1,-1), 2),
]))
story.append(rf_table)

# Microbiology
story.append(spacer(0.3))
story.append(section_header("5.  MICROBIOLOGY"))
story.append(spacer(0.2))
story.append(body("Most PLAs are <b>polymicrobial</b> (enteric + anaerobic organisms)."))
story.append(spacer(0.15))

micro_headers = ["Category", "Organisms", "Notes"]
micro_rows = [
    ["Gram-negative aerobes\n(most common)", "E. coli (most frequent), Klebsiella pneumoniae, Enterobacter spp., Pseudomonas spp., Proteus spp., Citrobacter spp.",
     "K. pneumoniae virulent strains → abscess without hepatobiliary disease; metastatic septic complications (endophthalmitis, meningitis)"],
    ["Gram-positive aerobes", "Streptococcus milleri (anginosus) group, Enterococcus spp., S. aureus, S. pyogenes",
     "S. aureus most common in children and septicaemia; Chronic granulomatous disease"],
    ["Anaerobes", "Bacteroides fragilis (most common anaerobe), Fusobacterium necrophorum, anaerobic streptococci, Peptostreptococcus, Prevotella spp.",
     "Improved cultivation → more anaerobic isolates detected"],
    ["Special situations", "Salmonella Typhi (recurrent pyogenic cholangitis); Candida spp. (immunocompromised); Mycobacterium tuberculosis (rare); Actinomyces, Clostridium (uncommon)",
     "Fungal abscesses in haematologic malignancy"],
]
story.append(make_table(micro_headers, micro_rows, [3.5*cm, 7*cm, 6.5*cm]))

# Clinical Features
story.append(spacer(0.3))
story.append(section_header("6.  CLINICAL FEATURES"))
story.append(spacer(0.2))

story.append(sub_header("Symptoms"))
symp = [
    ("<b>Fever with chills/rigors</b>", "Most common symptom (up to 90%); may be spiking or low-grade (insidious)"),
    ("<b>Right upper quadrant pain</b>", "Dull, constant; increases with movement. Referred to right shoulder or cough if abscess near dome"),
    ("Anorexia, nausea, malaise", "Constitutional symptoms; weight loss if chronic"),
    ("Presentation", "<b>Subacute/insidious</b> in most; symptoms may persist >1 month before diagnosis. Multiple abscesses → acute presentation with sepsis/shock"),
]
sym_t = Table(
    [[Paragraph(k, ParagraphStyle("SK", fontSize=9, fontName="Helvetica", leading=12)),
      Paragraph(v, ParagraphStyle("SV", fontSize=9, fontName="Helvetica", leading=12))] for k, v in symp],
    colWidths=[5*cm, 12*cm]
)
sym_t.setStyle(TableStyle([
    ("ROWBACKGROUNDS", (0,0), (-1,-1), [white, LIGHT_BLUE]),
    ("GRID", (0,0), (-1,-1), 0.3, BORDER_BLUE),
    ("TOPPADDING", (0,0), (-1,-1), 3),
    ("BOTTOMPADDING", (0,0), (-1,-1), 3),
    ("LEFTPADDING", (0,0), (-1,-1), 5),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]))
story.append(sym_t)
story.append(spacer(0.2))

story.append(sub_header("Signs"))
signs = [
    "Fever",
    "Tender hepatomegaly (accentuated by percussion/movement) — most consistent sign",
    "Jaundice — late feature; early only if biliary disease is the underlying cause",
    "Splenomegaly — unusual; only in chronic abscess",
    "Portal hypertension — may follow recovery if portal vein was thrombosed (pylephlebitis)",
]
for s in signs:
    story.append(bullet(s))

# Investigations
story.append(spacer(0.3))
story.append(section_header("7.  INVESTIGATIONS"))
story.append(spacer(0.2))

story.append(sub_header("A. Blood Tests"))
lab_headers = ["Test", "Finding", "Frequency"]
lab_rows = [
    ["WBC", "Leukocytosis", "70–90%"],
    ["Haemoglobin", "Normochromic, normocytic anaemia", "Common"],
    ["Alkaline Phosphatase (ALP)", "Mildly elevated", "~80%"],
    ["Total Bilirubin", "Elevated", "20–50%"],
    ["Transaminases (AST/ALT)", "Mildly elevated", "~60%"],
    ["Serum Albumin", "Hypoalbuminaemia (reflects chronicity)", "Variable"],
    ["PT / INR", "Mildly elevated in chronic cases", "Variable"],
    ["ESR", "Elevated", "Common"],
]
story.append(make_table(lab_headers, lab_rows, [5.5*cm, 7.5*cm, 4*cm]))
story.append(spacer(0.1))
story.append(note("None of these tests are specific — they raise suspicion that leads to imaging."))
story.append(spacer(0.2))

story.append(sub_header("B. Cultures (Critical)"))
cult = [
    "<b>Blood cultures</b>: positive in ~<b>50%</b> of cases — must be drawn <b>before antibiotics</b>",
    "<b>Aspirate cultures</b> (aerobic + anaerobic): yield ~90% (lower if antibiotics already started)",
    "<b>Serology for Entamoeba histolytica</b> (ELISA): in patients with epidemiologic risk factors",
]
for c in cult:
    story.append(bullet(c))
story.append(spacer(0.2))

story.append(sub_header("C. Imaging"))
img_headers = ["Modality", "Sensitivity", "Findings / Notes"]
img_rows = [
    ["Chest X-ray", "~50% abnormal", "Elevated right hemidiaphragm, right pleural effusion, right basal atelectasis"],
    ["Plain Abdominal X-ray", "Rarely helpful", "Air-fluid levels in cavity; portal venous gas (grave sign — high mortality)"],
    ["Ultrasound (first-line)", "80–95%", "Hypoechoic round/oval lesion; distinguishes solid from cystic; guides aspiration. Limitation: poor for dome lesions; operator-dependent"],
    ["CT (contrast-enhanced)\n— Investigation of Choice", "95–100%", "Hypodense lesion with rim enhancement (<20%); detects small/multiple abscesses and gas in cavity; identifies underlying cause. Gas in abscess = increased mortality"],
    ["MRI", "Higher than CT for small lesions", "Low T1, high T2 signal; gadolinium enhancement. No advantage over CT for diagnosis; better for biliary tree assessment"],
    ["ERCP", "—", "Indicated when biliary stones or cholestasis present on imaging"],
]
story.append(make_table(img_headers, img_rows, [3.8*cm, 3cm, 10.2*cm]))

# Differential Diagnosis
story.append(spacer(0.3))
story.append(section_header("8.  DIFFERENTIAL DIAGNOSIS"))
story.append(spacer(0.2))

story.append(sub_header("Pyogenic vs. Amebic Liver Abscess"))
comp_headers = ["Feature", "PYOGENIC", "AMEBIC"]
comp_rows = [
    ["Age", ">50 years", "20–40 years"],
    ["Sex ratio (M:F)", "1.5 : 1", "≥ 10 : 1"],
    ["Number", "Often MULTIPLE", "Usually SINGLE"],
    ["Location", "Either lobe (Right > Left)", "Right lobe, near diaphragm"],
    ["Presentation", "Subacute (insidious)", "Acute"],
    ["Jaundice", "Mild (late)", "Moderate"],
    ["Serology (E. histolytica)", "Negative", "Positive"],
    ["Pus character", "Purulent, foul-smelling", "'Anchovy sauce' — odourless (unless superinfected)"],
    ["Treatment", "Drainage + IV antibiotics", "Metronidazole alone (no drainage usually needed)"],
]
ct = make_table(comp_headers, comp_rows, [4.5*cm, 6.25*cm, 6.25*cm])
story.append(ct)
story.append(spacer(0.2))

story.append(sub_header("Other Differentials"))
other_dd = [
    ("Echinococcal cyst", "Endemic area, daughter cysts on imaging, positive serology"),
    ("Simple hepatic cyst", "Thin wall, no enhancement, no symptoms, no fever"),
    ("Hepatocellular carcinoma", "AFP elevated, arterial enhancement + washout on CT"),
    ("Hepatic metastasis", "Known primary, multiple lesions, no fever"),
    ("Inflammatory pseudotumour", "Young men, history of infection, biopsy needed for diagnosis"),
]
for cond, feat in other_dd:
    story.append(bullet(f"<b>{cond}</b>: {feat}"))

# Treatment
story.append(spacer(0.3))
story.append(section_header("9.  TREATMENT"))
story.append(spacer(0.2))
story.append(body("Treatment requires a <b>multimodal approach</b>: antibiotics + drainage + treatment of the underlying cause."))
story.append(spacer(0.15))

story.append(sub_header("Step 1 — Resuscitation & Supportive Care"))
story.append(bullet("IV fluids, correction of electrolytes"))
story.append(bullet("Send blood cultures × 2 <b>before</b> starting antibiotics"))
story.append(spacer(0.15))

story.append(sub_header("Step 2 — Empiric IV Antibiotics (Start Immediately)"))
abx_headers = ["Regimen", "Coverage", "Notes"]
abx_rows = [
    ["Ampicillin + Aminoglycoside + Metronidazole", "Gram-positive, gram-negative, anaerobes", "Classic triple therapy; avoid aminoglycoside in renal impairment"],
    ["3rd-gen Cephalosporin (e.g., Ceftriaxone) + Metronidazole", "Enteric gram-negatives + anaerobes", "Preferred regimen in most centres"],
    ["Piperacillin-Tazobactam", "Broad-spectrum (gram-positive + negative + anaerobes)", "Good single-agent option"],
]
story.append(make_table(abx_headers, abx_rows, [5*cm, 5*cm, 7*cm]))
story.append(spacer(0.1))
story.append(bullet("Narrow to targeted therapy once culture & sensitivity available"))
story.append(bullet("<b>Duration</b>: 14 days IV → oral for a total of <b>4–6 weeks</b>"))
story.append(bullet("Antibiotics alone (no drainage) → mortality <b>59–100%</b> — not acceptable"))
story.append(spacer(0.2))

story.append(sub_header("Step 3 — Drainage"))
drain_headers = ["Method", "Success Rate", "Details"]
drain_rows = [
    ["Percutaneous Catheter Drainage (PCD)\n— TREATMENT OF CHOICE",
     "66–90%",
     "US/CT-guided; catheter left in situ until output minimal (~7 days). Aspirate → Gram stain + aerobic/anaerobic culture. Relatively contraindicated: ascites, coagulopathy, proximity to vital structures"],
    ["Percutaneous Needle Aspiration\n(without indwelling catheter)",
     "60–90%\n(often needs >1 session)",
     "Majority require multiple aspirations (25% need ≥3). RCT: catheter 100% vs aspiration 60% success. Single aspiration trial is reasonable for small abscesses"],
    ["Surgical Drainage\n(Open or Laparoscopic)",
     "High (reserved for failures)",
     "Indicated: failed PCD; need to treat surgical primary cause (appendicitis, diverticulitis); ruptured abscess; multiple abscesses not amenable to PCD; large abscess >5 cm where PCD fails"],
    ["ERCP / Biliary Drainage",
     "—",
     "Indicated when underlying biliary obstruction (stones, stricture, malignancy) is identified — addresses the primary source"],
]
story.append(make_table(drain_headers, drain_rows, [4.5*cm, 3cm, 9.5*cm]))
story.append(spacer(0.2))

story.append(sub_header("Step 4 — Treat the Underlying Cause"))
story.append(bullet("Biliary disease (ERCP, cholecystectomy, biliary stenting)"))
story.append(bullet("GI malignancy — colonoscopy/endoscopy if K. pneumoniae or cryptogenic PLA"))
story.append(bullet("Diverticulitis, appendicitis — surgical management as appropriate"))

# Complications
story.append(spacer(0.3))
story.append(section_header("10.  COMPLICATIONS"))
story.append(spacer(0.2))
comp_left = [
    "Rupture — peritoneal cavity (peritonitis)",
    "Rupture — pleural cavity (empyema thoracis)",
    "Rupture — pericardium (purulent pericarditis)",
    "Septicaemia / septic shock",
]
comp_right = [
    "Portal vein thrombosis → portal hypertension",
    "Subphrenic abscess",
    "Biliary fistula",
    "Metastatic septic emboli (K. pneumoniae: endophthalmitis, meningitis)",
]
comp_data = []
for i in range(max(len(comp_left), len(comp_right))):
    l = bullet(comp_left[i]) if i < len(comp_left) else Paragraph("", body_style)
    r = bullet(comp_right[i]) if i < len(comp_right) else Paragraph("", body_style)
    comp_data.append([l, r])
comp_t = Table(comp_data, colWidths=[8.5*cm, 8.5*cm])
comp_t.setStyle(TableStyle([("VALIGN", (0,0), (-1,-1), "TOP"), ("TOPPADDING", (0,0), (-1,-1), 2), ("BOTTOMPADDING", (0,0), (-1,-1), 2)]))
story.append(comp_t)

# Prognosis
story.append(spacer(0.3))
story.append(section_header("11.  PROGNOSIS"))
story.append(spacer(0.2))
prog = [
    "Ochsner & DeBakey era (pre-antibiotic): mortality <b>70–80%</b>",
    "Modern mortality: <b>5–30%</b> with aggressive antibiotic therapy and drainage",
]
for p in prog:
    story.append(bullet(p))
story.append(spacer(0.15))
story.append(sub_header("Poor Prognostic Factors"))
poor = ["Jaundice", "Hypoalbuminaemia", "Multiple abscesses", "Underlying malignancy", "Gas in abscess cavity (plain X-ray finding)", "Delay in diagnosis / treatment", "Rupture"]
poor_data = [[bullet(poor[i]) if i < len(poor) else Paragraph("", body_style),
              bullet(poor[i+1]) if i+1 < len(poor) else Paragraph("", body_style)]
             for i in range(0, len(poor), 2)]
poor_t = Table(poor_data, colWidths=[8.5*cm, 8.5*cm])
poor_t.setStyle(TableStyle([("VALIGN", (0,0), (-1,-1), "TOP"), ("TOPPADDING", (0,0), (-1,-1), 2)]))
story.append(poor_t)

# Key Points
story.append(spacer(0.3))
story.append(section_header("12.  KEY POINTS  (SRB-STYLE SUMMARY)"))
story.append(spacer(0.2))

key_points = [
    "Most common <b>visceral abscess</b>; right lobe predominance (75%)",
    "<b>Biliary disease</b> = most common identifiable cause; <b>cryptogenic</b> predominates overall (~40%)",
    "Most common organisms: <b>E. coli</b> and <b>K. pneumoniae</b>; mostly <b>polymicrobial</b>",
    "Classic presentation: <b>Fever + RUQ pain + tender hepatomegaly</b> (+ jaundice if biliary origin)",
    "Presentation is usually <b>subacute/insidious</b>; multiple abscesses → more acute with sepsis",
    "<b>Contrast-enhanced CT</b> = investigation of choice (sensitivity 95–100%)",
    "<b>Blood cultures × 2</b> before antibiotics (positive in ~50%)",
    "<b>Percutaneous catheter drainage + IV antibiotics</b> = standard of care",
    "Surgery reserved for <b>failed PCD</b>, ruptured abscess, or concurrent surgical pathology",
    "<b>Klebsiella PLA</b> → screen for colorectal malignancy (fourfold risk); risk of metastatic septic foci",
    "Differentiate from <b>amebic abscess</b>: young male, single, right lobe, anchovy sauce pus, positive serology, responds to metronidazole alone without drainage",
    "Antibiotic duration: <b>2 weeks IV → 4–6 weeks total</b>",
]
for i, kp in enumerate(key_points, 1):
    story.append(key_point(i, kp))
    story.append(spacer(0.05))

# Sources
story.append(spacer(0.4))
story.append(hr())
story.append(Paragraph(
    "Sources: Sabiston Textbook of Surgery (The Biological Basis of Modern Surgical Practice) · "
    "Mulholland & Greenfield's Surgery: Scientific Principles and Practice, 7th ed. · "
    "Sleisenger & Fordtran's Gastrointestinal and Liver Disease",
    source_style
))

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