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Part VI ♦ Special Subjects

H. Cholangitis 1. Ascending infection of the biliary system associated with Charcot triad and Reynold pentad. 2. Ninety-five percent of cases are associated with gallstones. I. Pyelonephritis and nephrolithiasis 1. Typically present with flank pain. 2. Nephrolithiasis usually has associated hematuria. J. Appendicitis: Pain may be atypical, especially in pregnant women. II. RLQ pain A. Appendicitis 1. Pain typically starts periumbilical then moves to McBurney point, usually within a day. 2. Notoriously variable presentation. TRUSTED SOURCE Di Saverio et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery (2020) 15:27. Available at: https://www.wses.org.uk/wp-content/uploads/2020/04/acute- appendicitis-update.pdf. And American Family Physician: Point-of-Care Guides: Diagnosis of Appendicitis: Part I. History and Physical Examination. Available at: https://www.aafp.org/afp/2008/0315/ p828.html. TRUSTED SOURCE Society of American Gastrointestinal and Endoscopic Surgeons (SAGES): Clinical Spotlight Review: Management of Choledocholithiasis, February 2020. Available at: https://www.sages.org/publications/guidelines/clinical-spotlight-review- management-of-choledocholithiasis/ B. Diverticulitis: Typically left-side or pelvic pain, but can present with right- side pain. C. Cecal volvulus: Torsion results in closed-loop obstruction and pain. D. Colon cancer 1. Can present as pain, obstruction, bleeding, or perforation. 2. Fecal occult screening and routine colonoscopies increase detection before the mass becomes symptomatic. E. Meckel diverticulum: Rule of 2’s—2% of population, 2% symptomatic, and majority within 2 ft of the ileocecal valve. F. Renal system: UTI, nephrolithiasis, and pyelonephritis. G. Reproductive system: Gynecologic pain, prostatitis, and testicular torsion.

CUT TO CASEBOOK See NMS Surgery Casebook , 3rd edition, Case 8.14. Right Lower Quadrant Pain with Dysuria and Increased WBCs