Makindo Medical Notes

💡 Fitz–Hugh–Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease (PID) in which infection spreads to the liver capsule, causing perihepatitis and characteristic “violin-string” adhesions between the liver and the anterior abdominal wall or diaphragm. It is an important mimic of biliary or hepatic pathology in young women presenting with right upper quadrant pain.

🧠 About

• FHCS occurs in approximately 10% of women with PID and rarely in men (via ascending urethral infection).
• Pathology: Inflammation of Glisson’s capsule (liver surface) without hepatic parenchymal involvement.
• Fibrous adhesions may form, linking the liver capsule to the peritoneum or diaphragm.

🦠 Aetiology

• Chlamydia trachomatis – most common cause.
• Neisseria gonorrhoeae – less frequent but classic historical association.
• Occasionally polymicrobial or due to other genital tract organisms.

⚕️ Pathophysiology

• Ascending genital tract infection → fallopian tubes → peritoneal cavity → right upper quadrant via paracolic gutters.
• Inflammation of the liver capsule produces capsular enhancement and adhesion formation.
• Pain results from traction on the diaphragm and parietal peritoneum, explaining referred shoulder pain.

🩺 Clinical Features

• 🎯 Sharp right upper quadrant (RUQ) pain, often pleuritic or referred to the right shoulder or inner arm.
• Movement or coughing exacerbates pain; tenderness over RUQ on palpation.
• Fever, rigors, malaise, nausea, or vomiting.
• Pelvic or lower abdominal pain with mucopurulent vaginal discharge.
• Dyspareunia and menstrual irregularities (features of underlying PID).

🔍 Differential Diagnosis

• Cholecystitis or biliary colic.
• Viral or drug-induced hepatitis.
• Pyelonephritis or renal colic.
• Ectopic pregnancy.
• Pulmonary embolism or pleurisy (may cause referred pain).
• Appendicitis (particularly retrocecal).

🧪 Investigations

• Blood tests: FBC, U&E, LFTs, CRP, ESR — typically show inflammatory response; transaminases often mildly raised.
• Microbiology: Endocervical or vaginal NAAT for Chlamydia and Gonorrhoea.
• Imaging:
  • Chest X-ray — exclude basal pneumonia or perforation.
  • Ultrasound — normal gallbladder, may show perihepatic fluid.
  • CT or MRI — may show enhancement of the liver capsule in the arterial phase.
• Laparoscopy: Diagnostic gold standard — visualises “violin-string” adhesions between the liver capsule and anterior abdominal wall; allows sampling for culture and sensitivity.

💊 Management

• ⚕️ Hospital admission if unwell or diagnostic uncertainty.
• 📋 Multidisciplinary approach: involve gynaecology, microbiology, and surgery if peritonism or diagnostic overlap.
• 💉 Antibiotic therapy: Follow local PID protocol (e.g. NICE/UKHSA guidance):
  • Ceftriaxone 1 g IM single dose plus Doxycycline 100 mg PO twice daily for 14 days ± Metronidazole 400 mg PO twice daily for 14 days.
  • If severe or admitted: IV ceftriaxone and doxycycline ± metronidazole.
• 💊 Analgesia and antiemetics as required.
• 🧍‍♀️ Sexual health review: Notify and treat partners, screen for other STIs, offer HIV/syphilis testing.
• 📅 Follow-up: Clinical review at 72 hours; repeat STI testing in 6–12 weeks to confirm eradication.

🧠 Teaching Points

• RUQ pain in a young woman with PID should always raise suspicion of Fitz-Hugh-Curtis syndrome.
• Liver function tests are often only mildly abnormal — marked transaminitis suggests alternative diagnosis.
• Delay in treatment may lead to chronic pain or adhesion-related infertility.

📚 References

• NICE NG117 (2024): Pelvic Inflammatory Disease: diagnosis and management.
• Workowski KA et al. CDC STD Guidelines 2021.
• Peter NG et al. Fitz-Hugh–Curtis Syndrome: A diagnosis to consider in women with RUQ pain. Am Fam Physician. 2010.