Fitz-Hugh–Curtis syndrome is a rare complication of

pelvic inflammatory disease Pelvic inflammatory disease, also known as pelvic inflammatory disorder (PID), is an infection of the upper part of the female reproductive system, namely the uterus, fallopian tubes, and ovaries, and inside of the pelvis. Often, there may be ...

(PID) involving liver capsule

inflammation Inflammation (from la, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants, and is a protective response involving immune cells, blood vessels, and molec ...

leading to the creation of

adhesions Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connects tissues not normally connected. Pathophysiology Adhesions form as a natural ...

. The condition is named after the two physicians, Thomas Fitz-Hugh, Jr and

Arthur Hale Curtis Arthur Hale Curtis (May 20, 1881 – November 13, 1955) was an American football player, coach, and gynecologist. He served as the head coach at the University of Kansas in 1902 and at the University of Wisconsin–Madison from 1903 to 1904, comp ...

who first reported this condition in 1934 and 1930 respectively.

Signs and symptoms

The major symptom and signs include an acute onset of right upper quadrant (RUQ)

abdominal pain Abdominal pain, also known as a stomach ache, is a symptom associated with both non-serious and serious medical issues. Common causes of pain in the abdomen include gastroenteritis and irritable bowel syndrome. About 15% of people have a m ...

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. Surprisingly there is often no or only minimal pelvic pain, vaginal discharge or cervical motion tenderness, which may lead to the diagnosis being missed. This may be due to infectious bacteria bypassing pelvic structures on the way to the liver capsule.

Pathophysiology

Fitz-Hugh–Curtis syndrome occurs almost exclusively in women. It is usually caused by ''

Chlamydia trachomatis ''Chlamydia trachomatis'' (), commonly known as chlamydia, is a bacterium that causes chlamydia, which can manifest in various ways, including: trachoma, lymphogranuloma venereum, nongonococcal urethritis, cervicitis, salpingitis, pelvic infla ...

'' (Chlamydia) or ''

Neisseria gonorrhoeae ''Neisseria gonorrhoeae'', also known as ''gonococcus'' (singular), or ''gonococci'' (plural), is a species of Gram-negative diplococci bacteria isolated by Albert Neisser in 1879. It causes the sexually transmitted genitourinary infection gon ...

'' (Gonorrhea) though other bacteria such as ''

Bacteroides ''Bacteroides'' is a genus of Gram-negative, obligate anaerobic bacteria. ''Bacteroides'' species are non endospore-forming bacilli, and may be either motile or nonmotile, depending on the species. The DNA base composition is 40–48% GC. Unus ...

'', ''

Gardnerella ''Gardnerella'' is a genus of Gram-variable In microbiology and bacteriology, Gram stain (Gram staining or Gram's method), is a method of staining used to classify bacterial species into two large groups: gram-positive bacteria and gram-negat ...

'', '' E. coli'' and ''

Streptococcus ''Streptococcus'' is a genus of gram-positive ' (plural ) or spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales (lactic acid bacteria), in the phylum Bacillota. Cell division in streptococci occurs ...

'' have also been found to cause Fitz-Hugh-Curtis syndrome on occasion. These bacterial pathogens cause a thinning of cervical mucus and allow bacteria from the vagina into the

uterus The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The ...

and

fallopian tube The fallopian tubes, also known as uterine tubes, oviducts or salpinges (singular salpinx), are paired tubes in the human female that stretch from the uterus to the ovaries. The fallopian tubes are part of the female reproductive system. In o ...

s, causing infection and inflammation. Occasionally, this inflammation can cause scar tissue to form on

Glisson's capsule The liver is a major organ only found in vertebrates which performs many essential biological functions such as detoxification of the organism, and the synthesis of proteins and biochemicals necessary for digestion and growth. In humans, it is ...

, a thin layer of connective tissue surrounding the liver.(Bailey&Love)

Diagnosis

Abdominal ultrasound Abdominal ultrasonography (also called abdominal ultrasound imaging or abdominal sonography) is a form of medical ultrasonography (medical application of ultrasound technology) to visualise abdominal anatomical structures. It uses transmission a ...

will typically be normal.

Liver function tests Liver function tests (LFTs or LFs), also referred to as a hepatic panel, are groups of blood tests that provide information about the state of a patient's liver. These tests include prothrombin time (PT/INR), activated partial thromboplastin ti ...

will typically be normal or unchanged from baseline as the infection does not involve the liver parenchyma. If a

D-dimer D-dimer (or D dimer) is a fibrin degradation product (or FDP), a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis. It is so named because it contains two D fragments of the fibrin protein joined by a cros ...

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 Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medlin ...

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 Ceftriaxone, sold under the brand name Rocephin, is a third-generation cephalosporin antibiotic used for the treatment of a number of bacterial infections. These include middle ear infections, endocarditis, meningitis, pneumonia, bone and join ...

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. Laparoscopy for lysis of adhesions may be performed for refractory pain.

References

External links