INTRODUCTION

Originally described in 1920, Fitz-Hugh-Curtis (FHC) syndrome (formally known as Fitz-Hugh and Curtis syndrome) consists of right upper quadrant pain resulting from ascending pelvic infection and inflammation of the liver capsule or diaphragm. Although it typically is associated with acute salpingitis, it can exist without signs of acute pelvic inflammatory disease (PID). In that respect, FHC syndrome can mimic other abdominal emergencies and often is a diagnosis of exclusion.

Pathophysiology: FHC is an extrapelvic manifestation of PID. It is associated with right upper quadrant pain that likely results from inflammation of the liver capsule and diaphragm. Previously, Neisseria gonorrhoeae was thought to be the main causative agent. However, recent studies have shown that cases of FHC due to Chlamydia trachomatis infection outnumber those due to N gonorrhoeae infection by almost 5 to 1. The spread of bacteria from the pelvis to the liver capsule likely results from the circulation of abdominal fluid over the right paracolic gutter to the subphrenic space and hepatic surface. However, lymphatic and hematogenous spread have not been excluded, and these probably play a role in the dissemination of the disease.

Age:

CLINICAL PRESENTATION

History:

FHC consists of 2 phases, termed acute and chronic.

  • Acute phase
    • Acute onset of excruciating sharp pain over the area of the gallbladder
    • Possible referred pain to right shoulder
    • Pleuritic pain that increases with Valsalva (ie, any maneuver that increases intra-abdominal pressure, eg, cough, sneeze) or movement
    • Occasional nausea, vomiting, hiccups, chills, fever, night sweats, headaches, or general malaise
    • Most often associated with acute salpingitis but symptoms of FHC without signs of PID are possible
  • Chronic phase - Characterized by persistent right upper quadrant pain or relief of symptoms altogether
Physical examination

Without a diagnosis of PID, FHC most often is a diagnosis of exclusion.

  • Typically, no pathognomonic signs are present upon physical examination.
  • The diagnosis is inferred from symptoms and positive culture findings for gonorrheal or chlamydial organisms.
  • Listening at the anterior costal margin may reveal a finding described as a "walking-in-new-snow” type of crunching friction rub.

Causes: FHC is caused by infection with C trachomatis or N gonorrhoeae.

DIFFERENTIAL DIAGNOSIS

Abdominal Trauma, Blunt
Adrenal Carcinoma
Appendicitis
Cholecystitis
Cholelithiasis
Hepatitis, Viral
Nephrolithiasis
Pancreatitis, Acute
Pancreatitis, Chronic
Peptic Ulcer Disease
Pneumonia, Bacterial
Pneumonia, Fungal
Pneumonia, Viral
Pulmonary Embolism


Other Problems to be Considered:

Ectopic pregnancy
Pyelitis
Pyelonephritis
Pylephlebitis
Peritonitis
Subphrenic abscess

 

 

LABORATORY STUDIES

Test findings are consistent with those of acute PID.

    • Cervical cultures for gonorrhea and chlamydia

    • Elevated WBC count and erythrocyte sedimentation rate

  • Because FHC rarely affects liver parenchyma, LFT results rarely are affected.

  • Rule out other disease.

    • Amylase or lipase to help exclude gallbladder disease

    • LFTs to help exclude hepatitis

    • Urinalysis or urine culture to help exclude pyelonephritis or kidney stones

    • Stool guaiac to help exclude perforated ulcer

Imaging Studies:

  • Ultrasound

    • Case reports exist that indicate visualizing perihepatic adhesions may be possible, especially when fluid is present in the abdominal cavity.

    • One study found an increase in the width of anterior extrarenal tissue due to inflammation.

    • Ultrasound findings help exclude the presence of gallstones.

  • CT scan

    • CT scan findings may help delineate a loculated perihepatic peritoneal collection.

    • Findings help exclude the presence of other diseases.

  • Chest radiograph

    • The right hemidiaphragm may be elevated.

    • Findings help exclude the presence of pneumonia.

    • Check for free air to help rule out perforation.

Procedures:

  • Diagnostic laparoscopy

    • This is the criterion standard procedure for diagnosis.

    • Most diagnoses are made with after direct visualization of the liver capsule.

    • During the acute phase, inflammation of the peritoneum and anterior liver capsule is present and exudate that is gray and flaky or granular appears. The exudate has been described as looking like salt sprinkled on a moist surface.

    • During the chronic phase, the classic "violin-string” adhesions of the anterior liver capsule to the anterior abdominal wall or diaphragm are present.

TREATMENT

Medical Care:

  • Antibiotics are the mainstay of therapy.

  • Treatment is the same as for PID.

  • Patients may be treated in an outpatient setting unless they meet one of following criteria:

    • Positive for human immunodeficiency virus infection

    • Unilateral or bilateral tuboovarian abscess

o        Oral intake not possible due to secondary nausea or vomiting

o        Outpatient treatment has failed

o        Pregnant

Surgical Care:

  • Laparoscopy is the criterion standard for diagnosis.

  • Relief of symptoms with lysis of adhesions is of questionable benefit.

Activity:

  • Sexual activity should be restricted until the patient's partner is treated.

 

MEDICATION

Antibiotics and pain control agents are the medications of choice. Use the same antibiotics as would be used to treat PID.. Pain control may be achieved with NSAIDs or acetaminophen with codeine .

Drug Category: Outpatient antibiotic regimen -- Includes antibiotics to treat the common causes of PID. This regimen includes both ceftriaxone, doxycycline,ofloxacin and metronidazoloe.

CEFTRIAXONE:

250 mg IV/IM once

DOXYCYCLINE:

100 mg PO bid for 14 d

OFLOXACIN:

400 mg PO bid for 14 d

METRONIDAZOLE:

500 mg PO bid for 14 d      

Drug Category: Inpatient antibiotic regimen -- Includes antibiotics used to treat the common causes of PID. This regimen includes both cefotetan, doxycycline,clindamycin and gentamicin.

CEFOTETAN:

2 g IV q12h

DOXYCYCLINE:

100 mg PO/IV q12h

CLINDAMYCIN:

900 mg IV q8h

GENTAMICIN:

2 mg/kg loading dose IV, then 1.5 mg/kg q8h  

   

Drug Category: Analgesics -- Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.

ACETAMINOPHEN &CODEINE:

30-60 mg/dose based on codeine content PO q4-6h or 1-2 tab q4h; not to exceed 4 g/d of acetaminophen  

 

FOLLOW-UP

Further Inpatient Care:

  • Continue inpatient antibiotics until the patient is able to tolerate oral intake, is afebrile, and has improvement in abdominal pain.
  • Switch to an oral regimen to complete the 14-day antibiotic course.

Further Outpatient Care:

  • Perform a follow-up examination in 48-72 hours to document improvement of symptoms.
  • Treat the patient's sexual partner for gonorrhea and chlamydia.

Deterrence/Prevention:

  • Use condoms.
  • Limit the number of sexual partners.

Prognosis:

  • Prognosis is excellent.
  • Most cases are asymptomatic (ie, difficult to diagnose clinically) and are diagnosed only at the time of surgery, when FHC syndrome is in the chronic stage.