Fitz-Hugh Curtis syndrome

Synonyms: Fitz-Hugh and Curtis syndrome, FHC syndrome, Curtis-Fitz-Hugh syndrome

What is Fitz-Hugh Curtis syndrome?¹

Fitz-Hugh Curtis syndrome is defined as acute perihepatitis with typical “violin-string” adhesions between the liver and the anterior abdominal wall or the diaphragm, associated with pelvic inflammatory disease. In the majority of cases it is associated with chlamydial or gonococcal salpingitis.

How common is Fitz-Hugh Curtis syndrome? (Epidemiology)

• The epidemiology tends to mimic that of PID, affecting women of reproductive age and often younger women. The incidence of Fitz-Hugh Curtis syndrome ranges from 4 to 14 % in female with PID, reaching 27 % in adolescent cases.²

• However, the condition has been reported in the absence of PID.³

• It has also rarely been reported in male patients.^{4 5}

What causes Fitz-Hugh Curtis syndrome? (Aetiology)³

Initially, only Neisseria gonorrhoeae was considered a causative bacterium. However, in recent years, additional causative bacteria such as Chlamydia trachomatis have been reported
This condition has also been found to be caused by other bacterial sexually transmitted infections. Genital tuberculosis and appendicitis can also be associated.⁶

The spread of disease from the pelvis to the liver may be due to circulation of fluid along the paracolic gutter; it may be due to lymphatic drainage or it may be via the bloodstream.

Symptoms of Fitz-Hugh Curtis syndrome (presentation)

Fitz-Hugh Curtis syndrome usually presents with pain in the right hypochondrium and fever, associated with symptoms and signs of pelvic infection in women.⁷ However, there may be no symptoms of Fitz-Hugh Curtis syndrome and it is found incidentally at the time of investigations or surgery at a later date.

There is both an acute and a chronic phase. In the acute phase the following features are often found:

• Acute onset of severe, sharp pain in the right upper quadrant and especially over the area of the gallbladder.

• Pain which may be referred to the right shoulder.

• Pain which is pleuritic in nature and anything that increases intra-abdominal pressure, such as a cough, sneeze or movement, is associated with a sharp aggravation of the pain.

• There may possibly be:
  

  • Nausea.

  • Vomiting.

  • Hiccups.

  • Chills.

  • Fever.

  • Night sweats.

  • Headaches.

  • General malaise.

• There are often features of acute salpingitis but this is not invariable.

The chronic phase may show persistent, dull pain in the right upper quadrant or the pain may subside.

Examination

• There may be typical features of PID with lower abdominal tenderness, cervical excitation pain and tender adnexa

• Auscultation over the anterior costal margin may show a friction rub described as walking in new snow. This is similar to the sound of acute pericarditis.

• There may be no abnormalities on examination.

Differential diagnosis

The differential diagnosis includes that for pelvic pain and right upper quadrant pain. The presentation of this disease may mimic a number of others.⁸

The most important include:

• Ectopic pregnancy.

• Pyelonephritis.

• Cholecystitis.

• Viral hepatitis.

• Pulmonary embolism.

• Renal colic.

• Appendicitis.

• Pleurisy.

Often it is a diagnosis of exclusion.

Investigations

• Swabs should be taken for gonorrhoea and chlamydia. See also the separate Chlamydial Genital Infection article.

• FBC may show an elevated white count and erythrocyte sedimentation rate (ESR) may be raised.

• LFTs should be normal, as the parenchyma of the liver is not involved.

• Microscopy and culture of urine.

• Abdominal ultrasound to exclude renal or biliary stones. Diagnosis by ultrasound showing the 'violin string' and ascites has been reported.

• Enhanced multislice CT can also be of value.⁸

• A dynamic abdominal CT, including an arterial phase scan, can significantly improve the depiction of perihepatic enhancement.⁹

• CXR may be helpful to exclude pneumonia, pulmonary embolism and air under the diaphragm.

• A definitive diagnosis can be made based on detection of violin string-like adhesions or identification of causative organisms in hepatic capsular lesion specimens, which requires laparoscopy or laparotomy.⁹

• In the chronic phase, the classical 'violin-string' adhesions of the anterior liver capsule to the anterior abdominal wall or diaphragm may be seen.

Management of Fitz-Hugh Curtis syndrome

• Appropriate antibiotics of appropriate duration to treat the PID. This may depend on the results of culture. See also the separate Pelvic Inflammatory Disease article.

• Initial blind treatment of bacterial infection is usually recommended for sexually active women, unless another cause for the clinical signs can be identified.

• Analgesia may be required.

• It may be possible to divide some adhesions at laparoscopy.

When treating PID, remember to treat not just the patient but the sexual partner(s) too.

Complications of Fitz-Hugh Curtis syndrome³

Long-term complications of Fitz-Hugh Curtis syndrome are uncommon but include pelvic inflammatory complications:

• • Chronic pain.

  • Small intestinal obstruction due to adhesion.

  • Ectopic pregnancy.

  • Infertility.

Prognosis

• Prognosis is generally as for PID.⁹

• It may also be found as an incidental finding when investigating infertility and, as such, it may also indicate tubal damage.

Prevention

Prevention is as for PID.