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// ═══════════════════════════════════════════════════════════════════
//  SLIDES
// ═══════════════════════════════════════════════════════════════════

// ── SLIDE 1: Title ─────────────────────────────────────────────────
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  s.addText("ABDOMINAL\nABSCESS", {
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    { text:"Undergraduate Medical Programme", options:{ fontSize:13, color:C.subtleGray }},
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  s.addText("Bailey & Love | Sleisenger & Fordtran | Mulholland & Greenfield", {
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// ── SLIDE 2: Learning Objectives ───────────────────────────────────
contentSlide(pres, "Learning Objectives", [
  "Define intra-abdominal abscess (IAA) and understand its significance",
  "Identify common causes and predisposing risk factors",
  "Describe the pathophysiology of abscess formation",
  "Classify abdominal abscesses by anatomical location",
  "Enumerate the microbiology and bacteriology",
  "Recognise the clinical features and symptoms",
  "Outline the diagnostic investigations (imaging & lab)",
  "Discuss management: antibiotics, drainage, and surgery",
  "Identify complications and prognosis",
], {slideNum:2});

// ── SLIDE 3: Section 1 divider ─────────────────────────────────────
sectionSlide(pres, "1", "Definition & Overview");

// ── SLIDE 4: Definition ────────────────────────────────────────────
contentSlide(pres, "Definition", [
  "An intra-abdominal abscess (IAA) is a localized abdominal infection",
  "Arises in the background of infectious (secondary) peritonitis",
  "Represents a walled-off collection of pus within the peritoneal cavity or a retroperitoneal space",
  "##Types by peritonitis context:",
  ">Secondary peritonitis (most common) - bowel perforation, appendicitis, diverticulitis",
  ">Tertiary peritonitis - persistent/recurrent infection >48 hrs after treatment",
  "Solid organ abscesses (liver, spleen, pancreas) are a separate category",
  "Abscess formation = the body's attempt to CONTAIN infection and prevent fatal sepsis",
], {slideNum:4});

// ── SLIDE 5: Epidemiology & Importance ─────────────────────────────
contentSlide(pres, "Epidemiology & Importance", [
  "~8% of patients develop IAA after appendicectomy",
  "10-25% of hospitalised diverticulitis patients develop diverticular abscess",
  "Major cause of postoperative morbidity and mortality in surgical patients",
  "##Why it matters:",
  ">Significant cause of prolonged hospital stay and ICU admission",
  ">Can lead to sepsis, multi-organ failure if unrecognised",
  ">Preventable in many cases with good surgical technique",
  "Prompt diagnosis and drainage reduces mortality",
], {slideNum:5});

// ── SLIDE 6: Section 2 divider ─────────────────────────────────────
sectionSlide(pres, "2", "Aetiology & Risk Factors");

// ── SLIDE 7: Causes / Aetiology ────────────────────────────────────
twoColSlide(pres,
  "Causes of Intra-Abdominal Abscess",
  [
    "##Common Surgical Causes",
    "Perforated appendicitis",
    "Perforated peptic ulcer (gastric/duodenal)",
    "Diverticulitis with perforation",
    "Anastomotic leak post-colorectal surgery",
    "Cholecystitis / biliary perforation",
    "Pancreatitis (pancreatic abscess)",
    "Abdominal trauma",
  ],
  [
    "##Other Causes",
    "Crohn disease (entero-enteric fistula)",
    "Neoplastic disease (tumour perforation)",
    "Post-operative: retained sponge (gossypiboma)",
    "Pelvic inflammatory disease (PID)",
    "Iatrogenic - post-ERCP, post-angioembolisation",
    "Haematogenous spread (rare)",
  ],
  "", ""
);

// ── SLIDE 8: Risk Factors ──────────────────────────────────────────
contentSlide(pres, "Predisposing Risk Factors", [
  "##Host (Patient) Factors:",
  "Diabetes mellitus - impaired phagocytosis",
  "Malnutrition - decreased immune function",
  "Advancing age - diminished immune reserves",
  "Pre-existing organ dysfunction (renal, hepatic)",
  "Underlying malignancy",
  "Blood transfusion (immune modulation)",
  "##Iatrogenic / Drug-related Factors:",
  "Chronic glucocorticoid use - increased IAA risk",
  "Azathioprine for IBD - increases septic complications",
  "Anti-TNF-α therapy within 12 weeks of surgery (risk not clearly elevated per recent data)",
], {slideNum:8});

// ── SLIDE 9: Section 3 divider ─────────────────────────────────────
sectionSlide(pres, "3", "Pathophysiology");

// ── SLIDE 10: Pathophysiology Part 1 ──────────────────────────────
contentSlide(pres, "Pathophysiology - How Does an Abscess Form?", [
  "Bacteria enter peritoneal cavity via bowel perforation or surgical contamination",
  "##Host Defence Response:",
  "Peritoneal macrophages phagocytose bacteria → cleared by lymphatics",
  "Lymphatic drainage via diaphragmatic pumping is highly efficient",
  "##When defences are overwhelmed:",
  "PMN leucocytes invade → splanchnic blood flow increases",
  "Protein and fluid exudate into peritoneal cavity",
  "Fibrinogen + reduced plasminogen activator → FIBRIN DEPOSITION",
  "Fibrin entraps bacteria → localization of infection",
  "Peritoneal recesses, pouches, and spaces facilitate compartmentalisation",
  "Result: walled-off abscess = CONTAINED infection",
], {slideNum:10});

// ── SLIDE 11: Pathophysiology Part 2 ──────────────────────────────
contentSlide(pres, "Pathophysiology - Adjuvant Substances & Abscess Expansion", [
  "Adjuvant substances WORSEN abscess formation:",
  ">Haemoglobin (iron) - provides bacterial nutrients",
  ">Barium / faecal particles - block lymphatic vessels",
  ">Necrotic tissue - impairs bacterial killing",
  "##Dual effect of fibrin:",
  "Beneficial: traps bacteria, prevents sepsis",
  "Harmful: impairs antibiotic penetration and phagocytic migration",
  "##Net consequence of peritoneal defences:",
  "Lymphatic clearance → can cause bacteraemia",
  "Fluid exudate → hypovolaemia + dilution of opsonins",
  "Abscess formation = 'bacterial apoptosis' - sacrifices extraintestinal bacteria to prevent host death",
], {slideNum:11});

// ── SLIDE 12: Section 4 divider ────────────────────────────────────
sectionSlide(pres, "4", "Anatomical Classification");

// ── SLIDE 13: Classification by Location ──────────────────────────
contentSlide(pres, "Anatomical Classification of Abdominal Abscesses", [
  "##INTRAPERITONEAL ABSCESSES",
  ">Subphrenic (subdiaphragmatic) - right or left",
  ">Subhepatic - between liver and transverse colon",
  ">Pelvic abscess - most common site (appendix often pelvic)",
  ">Paracolic / pericolic - alongside colon",
  ">Interloop abscess - between bowel loops",
  ">Lesser sac abscess - behind stomach",
  "##RETROPERITONEAL ABSCESSES",
  ">Perinephric abscess",
  ">Psoas abscess",
  "##SOLID ORGAN ABSCESSES",
  ">Hepatic abscess | Splenic abscess | Pancreatic abscess",
], {slideNum:13});

// ── SLIDE 14: Subphrenic Abscess ──────────────────────────────────
contentSlide(pres, "Subphrenic Abscess", [
  "Pus immediately beneath the diaphragm (right > left side)",
  "##Classic causes:",
  "Post-appendicectomy, post-gastric surgery, post-biliary surgery",
  "##Symptoms:",
  "Spiking evening pyrexia - characteristic pattern",
  "Shoulder tip pain (C4/C5 dermatome referred pain)",
  "Hiccoughs due to diaphragmatic irritation",
  "##Signs:",
  "High, immobile diaphragm on affected side (CXR / screening)",
  "Clinical adage: 'Pus somewhere, pus nowhere, pus under the diaphragm'",
  "##Management: Percutaneous CT/US-guided drainage (preferred) or surgical drainage",
], {slideNum:14});

// ── SLIDE 15: Pelvic Abscess ───────────────────────────────────────
contentSlide(pres, "Pelvic Abscess", [
  "Most common site of intra-abdominal abscess formation",
  "Appendix often pelvic in position; Fallopian tubes also frequent source",
  "Common sequel to diffuse peritonitis or anastomotic leak after colorectal surgery",
  "##Symptoms:",
  "Pelvic pain, diarrhoea, passage of mucus per rectum",
  "Lower back pain / pressure sensation in pelvis",
  "May spontaneously discharge into anal canal via anastomotic leak",
  "##Signs: Tender pelvic mass on PR/PV examination",
  "##Management:",
  "CT or US confirmation",
  "Transanal or transgluteal percutaneous drainage",
  "Laparotomy if above fails",
], {slideNum:15});

// ── SLIDE 16: Section 5 divider ────────────────────────────────────
sectionSlide(pres, "5", "Microbiology & Bacteriology");

// ── SLIDE 17: Bacteriology ─────────────────────────────────────────
twoColSlide(pres,
  "Microbiology of Intra-Abdominal Abscess",
  [
    "##Community-acquired (Secondary peritonitis)",
    "Polymicrobial - gut flora predominate",
    "Escherichia coli - early predominant aerobe",
    "Bacteroides fragilis - late predominant anaerobe",
    "Anaerobic streptococci",
    "Klebsiella, Proteus species",
    "Enterococcus species",
    "##Key synergy:",
    "E. coli creates anaerobic microenvironment for B. fragilis",
    "B. fragilis impairs host phagocytosis of E. coli",
  ],
  [
    "##Hospital-acquired / ICU (Tertiary peritonitis)",
    "Resistant Gram-negative organisms",
    "Enterococcus species",
    "Candida (yeast) - most common in ICU (41%)",
    "Enterobacter (21%)",
    "Staphylococcus epidermidis (21%)",
    "E. coli and Bacteroides each only ~7-17%",
    "##B. fragilis virulence:",
    "8 types of capsular polysaccharides",
    "Polysaccharide A (PSA) triggers IL-17 and IL-10 → abscess formation",
    "Fibrinogenolytic proteases → may cause bacteraemia",
  ],
  "", ""
);

// ── SLIDE 18: Section 6 divider ────────────────────────────────────
sectionSlide(pres, "6", "Clinical Features");

// ── SLIDE 19: Symptoms & Signs ─────────────────────────────────────
twoColSlide(pres,
  "Clinical Features of Abdominal Abscess",
  [
    "##SYMPTOMS",
    "Malaise, lethargy, failure to recover as expected post-op",
    "Anorexia and weight loss",
    "Sweats ± rigors",
    "Fever - classic 'swinging pyrexia'",
    "Abdominal / pelvic pain",
    "##Location-specific symptoms:",
    "Subphrenic: shoulder tip pain, hiccoughs",
    "Lesser sac / perigastric: nausea, early satiety",
    "Interloop: ileus, distension, vomiting",
    "Pelvic: tenesmus, rectal urgency, mucus per rectum",
  ],
  [
    "##SIGNS",
    "Pyrexia (often spiking), tachycardia",
    "Localised abdominal tenderness ± mass",
    "Tender mass on PR/PV exam (pelvic abscess)",
    "##Classic tetrad (not always present):",
    "1. Abdominal pain",
    "2. Fever with chills",
    "3. Palpable abdominal mass",
    "4. Leucocytosis",
    "##Special note:",
    "Elderly and immunocompromised patients may present subtly",
    "Maintain HIGH clinical suspicion in post-op patients with prolonged ileus or fever",
  ],
  "", ""
);

// ── SLIDE 20: Section 7 divider ────────────────────────────────────
sectionSlide(pres, "7", "Investigations");

// ── SLIDE 21: Laboratory Investigations ───────────────────────────
contentSlide(pres, "Laboratory Investigations", [
  "##Blood Tests:",
  "Full Blood Count (FBC) - leucocytosis (WBC >12,000/mm³)",
  "C-Reactive Protein (CRP) - elevated; serial monitoring tracks treatment response",
  "Blood cultures - obtain BEFORE starting antibiotics",
  "Serum electrolytes, urea, creatinine - baseline organ function",
  "Liver function tests (if hepatic abscess suspected)",
  "Serum procalcitonin - marker of bacterial sepsis",
  "##Aspirate:",
  "Gram stain + culture of aspirated fluid = definitive diagnosis",
  "Guides targeted antibiotic therapy",
], {slideNum:21});

// ── SLIDE 22: Imaging - Ultrasound & CT ───────────────────────────
contentSlide(pres, "Imaging Investigations", [
  "##Ultrasound (US):",
  "First-line; rapid, no radiation, bedside-available",
  "Useful in children and pregnant patients",
  "Appearance: anechoic to complex echogenic fluid collection",
  "Limitation: operator-dependent; poor for deep/gas-containing collections",
  "##CT Scan (GOLD STANDARD):",
  "Sensitivity 96%, Specificity 95%, Accuracy 96% for acute abdominal pathology",
  "Classic appearance: rim-enhancing fluid collection ± gas (air-fluid level)",
  "Oral + IV contrast optimises detection",
  "Identifies complications: bowel obstruction, pylephlebitis, fistula",
  "Guides percutaneous drainage",
  "Multi-detector CT (MDCT) provides coronal/sagittal reconstructions",
], {slideNum:22});

// ── SLIDE 23: Imaging - MRI & Nuclear ─────────────────────────────
contentSlide(pres, "Advanced Imaging", [
  "##MRI:",
  "Superior soft-tissue contrast; no radiation",
  "Useful for interloop and retroperitoneal abscesses",
  "T2-weighted: fluid appears bright; DWI useful for pus characterisation",
  "Good for pregnancy, paediatric cases, and when CT is inconclusive",
  "##Plain X-Ray (AXR/CXR):",
  "Low sensitivity (30%) and specificity",
  "May show: gas under diaphragm, air-fluid levels, high immobile diaphragm",
  "##Nuclear Medicine:",
  "Radiolabelled leucocyte scan - whole-body, high sensitivity & specificity",
  "Drawback: 18-72 hours to complete; not routinely available",
  "18F-FDG PET/CT - test of choice in fever of unknown origin; cannot differentiate sterile vs infected",
  "Gallium scan - limited by false positives from bowel uptake",
], {slideNum:23});

// ── SLIDE 24: Section 8 divider ────────────────────────────────────
sectionSlide(pres, "8", "Management");

// ── SLIDE 25: General Principles & Resuscitation ─────────────────
contentSlide(pres, "Management - General Principles", [
  "##The TRIAD of Management:",
  "1. Resuscitation & Stabilisation",
  "2. Antibiotic Therapy",
  "3. Source Control (Drainage or Surgery)",
  "##Step 1 - Resuscitation:",
  "IV fluid resuscitation with crystalloids (follow Surviving Sepsis Campaign)",
  "Oxygen supplementation; monitor urine output",
  "Correct electrolyte imbalances",
  "Analgesia",
  "##Monitoring:",
  "Serial CRP useful to non-invasively monitor treatment response",
  "Blood cultures BEFORE starting antibiotics",
  "Catheter for urine output monitoring in sepsis",
], {slideNum:25});

// ── SLIDE 26: Antibiotic Therapy ──────────────────────────────────
contentSlide(pres, "Antibiotic Therapy", [
  "Start empirical antibiotics PROMPTLY after blood cultures taken",
  "##Target organisms (community-acquired / secondary peritonitis):",
  "Cover Gram-negative aerobes (E. coli, Klebsiella)",
  "Cover anaerobes (Bacteroides fragilis)",
  "##Empirical regimen options:",
  "Piperacillin-tazobactam (monotherapy) - broad spectrum",
  "Cefuroxime + Metronidazole (combination)",
  "Carbapenems (Imipenem, Meropenem) - for resistant organisms / ICU",
  "##Important considerations:",
  "No RCTs showing one agent superior - use non-inferiority data",
  "Adjust based on local hospital antibiogram",
  "ICU/tertiary peritonitis: add antifungal (Fluconazole / Caspofungin) if Candida suspected",
  "De-escalate based on culture sensitivities",
  "Duration: typically 5-7 days after source control",
], {slideNum:26});

// ── SLIDE 27: Drainage - Percutaneous & Surgical ──────────────────
contentSlide(pres, "Source Control - Drainage Options", [
  "##Percutaneous Image-Guided Drainage (PREFERRED when feasible):",
  "CT or US-guided drain placement",
  "Indications: unilocular abscess, accessible collection, radiological expertise available",
  "Success rate: up to 80% non-operative",
  "Best results: unilocular, transabdominal route",
  "Drain left in situ for 7-10 days; sinogram before removal",
  "##Abscess <5 cm: antibiotics alone may suffice (monitor closely)",
  "##Abscess >5 cm: percutaneous drainage or surgical intervention required",
  "##Surgical Drainage (Open or Laparoscopic):",
  "Indicated when: percutaneous fails, multilocular/complex collection, worsening sepsis",
  "Laparoscopic lavage for washout of peritoneal cavity",
  "Open laparotomy for extensive contamination or bowel resection needed",
  "Technical challenges: matted bowel loops, difficult access",
], {slideNum:27});

// ── SLIDE 28: Specific Site Management ────────────────────────────
contentSlide(pres, "Management by Location", [
  "##Subphrenic abscess:",
  "CT/US-guided percutaneous drainage preferred",
  "Surgical: extraperitoneal approach if image-guided fails",
  "Large-bore drain; left 7-10 days",
  "##Pelvic abscess:",
  "Transanal or transgluteal percutaneous drainage",
  "Laparotomy if above fails",
  "Transintestinal drainage no longer used (high fistula rate)",
  "##Interloop abscess:",
  "Usually NOT amenable to percutaneous drainage",
  "Surgical washout / laparoscopic lavage often required",
  "##Diverticular abscess (Hinchey I/II):",
  "Small (<3 cm): antibiotics alone",
  "Large (>3 cm): image-guided drainage + antibiotics",
  "Failed non-op → emergency colectomy (Hartmann procedure for Hinchey III/IV)",
], {slideNum:28});

// ── SLIDE 29: Complications ────────────────────────────────────────
contentSlide(pres, "Complications", [
  "##If untreated or inadequately treated:",
  "Septicaemia → Systemic Inflammatory Response Syndrome (SIRS)",
  "Multi-organ dysfunction / failure (MOF)",
  "Death",
  "##Local complications:",
  "Fistula formation (entero-cutaneous, colovesical)",
  "Bowel obstruction (adhesions)",
  "Portal pyaemia / pylephlebitis (septicaemia in portal venous system)",
  "Hepatic abscess (from portal pyaemia)",
  "SMV thrombosis (superior mesenteric vein)",
  "##After drainage:",
  "Recurrence (15-25% after diverticular abscess drainage)",
  "Persistent collection requiring re-drainage",
  "Drain-site infection / hernia",
], {slideNum:29});

// ── SLIDE 30: Summary & Key Points ────────────────────────────────
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    { text:"Pathophysiology: fibrin entrapment of bacteria in peritoneal recesses\n", options:{color:C.white,fontSize:13,breakLine:true,bullet:{code:"25CF",color:C.gold}}},
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    { text:"CT scan = gold standard investigation (sensitivity 96%)\n", options:{color:C.white,fontSize:13,breakLine:true,bullet:{code:"25CF",color:C.gold}}},
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    { text:"Pelvic abscess = most common site; Subphrenic = swinging fever + shoulder pain\n", options:{color:C.white,fontSize:13,breakLine:true,bullet:{code:"25CF",color:C.gold}}},
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// ── SLIDE 31: References ───────────────────────────────────────────
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    { text:"1. Bailey & Love's Short Practice of Surgery, 28th Edition. Norman Williams, Ronan O'Connell, Andrew W. McCaskie. 2023.\n", options:{fontSize:12,color:C.textDark,breakLine:true}},
    { text:"2. Sleisenger and Fordtran's Gastrointestinal and Liver Disease, 11th Edition. Feldman M, Friedman LS, Brandt LJ. Elsevier.\n", options:{fontSize:12,color:C.textDark,breakLine:true}},
    { text:"3. Mulholland and Greenfield's Surgery: Scientific Principles and Practice, 7th Edition. Jones DB et al. Wolters Kluwer.\n", options:{fontSize:12,color:C.textDark,breakLine:true}},
    { text:"4. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th Edition. Tintinalli JE et al. McGraw-Hill.\n", options:{fontSize:12,color:C.textDark,breakLine:true}},
    { text:"5. Pye's Surgical Handicraft, 22nd Edition. Lumley JSP, Craven JL, Aitken RJ.\n", options:{fontSize:12,color:C.textDark,breakLine:true}},
    { text:"6. Current Surgical Therapy, 14th Edition. Cameron JL, Cameron AM. Elsevier.", options:{fontSize:12,color:C.textDark}},
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