Fitz-Hugh–Curtis syndrome
Perihepatic adhesions

Fitz-Hugh–Curtis syndrome is a rare complication of pelvic inflammatory disease (PID) involving liver capsule inflammation[1] leading to the formation of adhesions presenting with the clinical syndrome of right upper quadrant (RUQ) pain.

History

Fitz-Hugh–Curtis syndrome, or perihepatitis, was first described by Carlos Stajano in 1920, who found adhesions between the liver capsule and the abdominal wall in patients suffering from gonococcal infections.[2]

The condition is named after the two physicians, Thomas Fitz-Hugh, Jr and Arthur Hale Curtis who further studied the syndrome in the 1930s. They noted the classic "violin string adhesions" in female patients presenting with RUQ abdominal pain. Both Fitz-Hugh and Curtis regularly found these adhesions during laparotomy in patients with the clinical syndrome of RUQ with concern for gallbladder pathology; however, no abdominal pathology was found in these patients but residual gonococcal tubal changes were often noted.[3][4]

Pathophysiology

Fitz-Hugh–Curtis syndrome occurs almost exclusively in women, though it can be seen in males rarely.[5] It is complication of pelvic inflammatory disease (PID) caused by Chlamydia trachomatis (Chlamydia) or Neisseria gonorrhoeae (Gonorrhea) though other bacteria such as Bacteroides, Gardnerella, E. coli and Streptococcus have also been found to cause Fitz-Hugh–Curtis syndrome on occasion.[6] Fitz-Hugh–Curtis syndrome was originally studied solely as a complication of PID secondary to Gonorrhea, but studies have now shown that Chlamydia is the most common causal pathogen.[7] Fitz-Hugh-Curtis syndrome occurs in 5-15% of patients with PID.[8]

The pathogens of PID spread either spontaneous secondary to an ascending infection through the fallopian tubes, lymphatically, or hematogenous.[9][10][11] Inflammation then causes scar tissue to form on Glisson's capsule, a thin layer of connective tissue surrounding the liver.[12] This inflammation and scaring then leads to the characteristic RUQ pain.

Presentation

The major symptom and signs include an acute onset of RUQ abdominal pain aggravated by breathing, coughing or laughing, which may be referred to the right shoulder. There is usually also tenderness on palpation of the right upper abdomen and tenderness to percussion of the lower ribs which protect the liver. Patients are most often women of childbearing age.

Differential Diagnosis

The signs and symptoms of Fitz-Hugh-Curtis syndrome greatly overlap with numerous other abdominal and pelvic pathologies. It is important for practitioners to person for a thorough history and physical as the differential for the symptoms of Fitz-Hugh-Curtis syndrome include cholecystitis, appendicitis, hepatitis, pregnancy, pyelonephritis, renal colic, among many others.

Diagnosis

Abdominal ultrasound will typically be normal. Liver function tests will typically be normal or unchanged from baseline as the infection does not involve the liver parenchyma. If a D-dimer is ordered, which it often is when there is pleuritic torso pain, it will usually be markedly elevated but other testing for pulmonary embolism will be normal. CT of the abdomen with IV contrast may show subtle enhancement of the liver capsule, but this may be missed by radiologists if they are not advised to look for it. Testing for gonorrhea and chlamydia should be performed to make the diagnosis. An endocervical or low vaginal swab should be taken to test for these organisms. Antibody testing is rarely required but may be considered if other tests are non-diagnostic and suspicion is high.Laparoscopy is also rarely required, but may be performed when the diagnosis is uncertain and may reveal "guitar string" adhesions of parietal peritoneum to liver.

Treatment

Treatment involves a course of antibiotics to cover the appropriate organisms, typically ceftriaxone plus azithromycin. The underlying infection may be treated using various regimens consisting of tetracycline, doxycycline, ofloxacin, metronidazole, and other antibiotics. Analgesics such as acetaminophen and codeine may be used to relieve pain.[13] Laparoscopy for lysis of adhesions may be performed for refractory pain.

References

  1. ↑ Peter, N. G.; Clark, L. R.; Jaeger, J. R. (2004). "Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain". Cleveland Clinic Journal of Medicine. 71 (3): 233–239. doi:10.3949/ccjm.71.3.233. PMID 15055246. S2CID 24756680.
  2. ↑ Stajano, Carlos. "La reaccion frenica en ginecologia". Semana Medica Buenes Aires. 27: 243–248.
  3. ↑ Fitz-Hugh, Thomas (1934). "Acute gonococcic peritonitis of the right upper quadrant in women". JAMA. 102 (25): 2094–5. doi:10.1001/jama.1934.02750250020010.
  4. ↑ Curtis, Arthur H. (1930). "A cause of adhesions in the right upper quadrant". JAMA. 94 (16): 1221–2. doi:10.1001/jama.1930.02710420033012.
  5. ↑ Lopez-Zeno, J. A.; Keith, L. G.; Berger, G. S. (August 1985). "The Fitz-Hugh-Curtis syndrome revisited. Changing perspectives after half a century". The Journal of Reproductive Medicine. 30 (8): 567–582. ISSN 0024-7758. PMID 2931518.
  6. ↑ Pelvic Inflammatory Disease at eMedicine
  7. ↑ Harrison's principles of internal medicine (21st ed.). New York: McGraw Hill. 2022. p. 1447. ISBN 978-1-264-26850-4.
  8. ↑ Wing, Edward J.; Schiffman, Fred J., eds. (2022). Cecil essentials of medicine (Tenth ed.). Philadelphia, PA: Elsevier. p. 936. ISBN 978-0-323-72271-1.
  9. ↑ You, Je Sung; Kim, Min Joung; Chung, Hyun Soo; Chung, Yong Eun; Park, Incheol; Chung, Sung Phil; Kim, Seungho; Lee, Hahn Shick (2012-07-01). "Clinical features of Fitz-Hugh-Curtis Syndrome in the emergency department". Yonsei Medical Journal. 53 (4): 753–758. doi:10.3349/ymj.2012.53.4.753. ISSN 1976-2437. PMC 3381477. PMID 22665342.
  10. ↑ Wølner-Hanssen, P.; Weström, L.; Mårdh, P. A. (1980-04-26). "Perihepatitis and chlamydial salpingitis". Lancet (London, England). 1 (8174): 901–903. doi:10.1016/s0140-6736(80)90838-7. ISSN 0140-6736. PMID 6103259. S2CID 20898724.
  11. ↑ Coremans, Laura; de Clerck, Frederik (2018-03-20). "Fitz-Hugh-Curtis syndrome associated with tuberculous salpingitis and peritonitis: a case presentation and review of literature". BMC Gastroenterology. 18 (1): 42. doi:10.1186/s12876-018-0768-0. ISSN 1471-230X. PMC 5859724. PMID 29558895.
  12. ↑ Bailey & Love's Short Practice of Surgery - 28th Edition
  13. ↑ "Fitz Hugh Curtis Syndrome". NORD. Retrieved 1 March 2023.

Further reading

  • Pregerson, Brady (2010). Quick Essentials: Emergency Medicine (4th ed.). ISBN 978-0-9761552-3-2.
  • Pregerson, D. Brady (2012). Tarascon Emergency Department Quick Reference Guide. Jones & Bartlett. ISBN 978-0-7637-8789-9.
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