Fitz-Hugh-Curtis Syndrome

Introduction

The Fitz-Hugh-Curtis syndrome can be defined as a rare complication that occurs in patients diagnosed with the pelvic inflammatory disease. This condition bears the name of the doctors who discovered it, meaning Fitz-Hugh and Curtis. One of the most important changes that occurs is related to the inflammation of the liver capsule, followed by the appearance of adhesions in the respective area. The adhesions form between the anterior part of the liver capsule and the anterior abdominal wall.

The complication might also affect the diaphragm, which is the respiratory muscle separating the thorax from the abdomen (in this situation, the adhesions are formed between the same part of the liver capsule and the diaphragm). The symptoms of the syndrome, as you will have the opportunity to read in the paragraphs below, can mimic other medical problems, such as cholecystitis or pyelonephritis.

The prevalence of this complication in women who suffer from the pelvic inflammatory disease is between 4-10%. In the situation that one suffers from genital tuberculosis, the prevalence of the Fitz-Hugh-Curtis syndrome is higher. Women who are in their child-bearing years are most commonly affected by such complications. Adolescents are also affected by this syndrome, as the frequency of the pelvic inflammatory disease is high in that period of life (plus, their immature anatomy is a serious risk factor). In extremely rare situations, this condition has been encountered in men as well.

Signs and Symptoms of Fitz-Hugh-Curtis Syndrome

These are the most common signs and symptoms that are present in patients suffering from such complications:

• Pain
  • Acute onset
  • Location – abdomen (right quadrant)
  • The pain is aggravated by breathing, coughing or laughing (this is because these movements increase the intra-abdominal pressure)
  • May radiate to the right shoulder
  • Pleuritic chest pain can also be present among the symptoms
• Tenderness in the right upper abdomen upon palpation
• The tenderness can be elicited through the percussion of the lower ribs (as these protect the liver)
• Systemic symptoms
  • Fever and/or chills
  • Headaches
  • Nausea, vomiting
  • Night sweats
  • State of general malaise
• Other symptoms
  • Hiccups
  • Features of acute salpingitis (not common)

It is important to mention that the patient might present little or even no pain in the pelvic area. There is no vaginal discharge and no tenderness related to the cervical motion, the lack of such symptoms often guiding the diagnosis in the wrong direction. It is believed that these changes are not present due to the bacteria bypassing the structures of the pelvis, before reaching the capsule of the liver and causing the inflammation in the area.

If the patient suffers from a chronic form of this complication, the pain might be dull in persistent, affecting mainly the right upper quadrant. In other patients, suffering as well from the chronic form, the pain subsides.

Pathophysiology

Women are clearly affected by this condition. The most common causes that lead to the appearance of such complications include: gonorrhea (this type is also known as the acute gonococcal perihepatitis) and chlamydia (bacterial infection as well). The latter causes the cervical mucus to become thinner, which in turn allows for the bacteria to travel from the vagina to the uterus and other adjacent structures (oviducts). The infectious organisms is responsible for the inflammation and it may also lead to the formation of scar tissue on the liver capsule. The latter is known as Glisson’s capsule, being a thin layer of connective tissue that surrounds the liver.

Chlamydia trachomatis is the most common bacterial agent involved in the appearance of this syndrome, followed by Neisseria gonorrhoeae. Other infectious agents that may cause such health problems in rare cases include: E. coli, Gardnerella and streptococcus.

Basically, in the Fitz-Hugh-Curtis syndrome, the infection is spread intraperitoneal, from the initial pelvic area (localized infection) to the perihepatic region. Recent studies have demonstrated that the spread of the infection from the pelvis to the liver area is due to the fluid circulating along the paracolic gutter. The infection might be transmitted through the lymphatic system or directly through the bloodstream.

Diagnosis

These are the most common methods used for the diagnosis of the Fitz-Hugh-Curtis syndrome:

Ultrasound

• Performed at the level of the abdomen
• Does not reveal any specific changes
• Incidental discovery of fat on the liver or gallstones
• Useful for the exclusion diagnosis (renal or biliary stones)
• Identification of changes such as the violin strings or excess fluid in the abdomen (ascites)

Blood testing

• Liver function tests
  • Normal or unchanged
  • The infection does not penetrate into the structure of the liver (hence the normal values of the liver enzymes)
• FBC
  • Elevated white count
  • Increased ESR (erythrocyte sedimentation rate)

Abdominal CT (with IV contrast)

• Subtle enhancement of the liver capsule
• May also show the inflammatory process that has occurred at the level of the pelvis
• A tubo-ovarian abscess can be identified
• In the perihepatic area, the following additional changes can be identified:
  • Inflammation and fluid collection at the level of the paracolic gutter
  • Thickening of the gallbladder wall
  • Transient perfusion abnormalities

Cervical samples

• Identification of infectious organisms (chlamydia, gonorrhea)
• Taking cervical samples is considered to be a more faithful investigation of the infectious organisms, in comparison to the urine analysis

Antibody testing

• Rarely required
• Recommended in the situation when the suspicion for this diagnostic is high (and other tests do not provide the desired information)

Laparoscopy

• Rarely required as well
• Performed when diagnosis is uncertain
• May reveal adhesions of the parietal peritoneum to the liver (characteristic aspect – violin strings)

Urine analysis

• Microscopy and culture
• Can be used in conjunction with other investigations for the confirmation of the infectious agent

CXR

• Useful for excluding the diagnosis of pneumonia or the pulmonary embolism.

The diagnosis of the Fitz-Hugh-Curtis syndrome can also be identified by taking samples from the peritoneal fluid. This will most likely contain the infectious microorganisms, such as chlamydia trachomatis or Neisseria gonorrhoeae. Other infectious microorganisms, such as trichomonas vaginalis, ureaplasma urealyticum or mycoplasma hominis can be identified in the fluid from the peritoneal cavity (in rare cases). As it was already mentioned, the syndrome can be found in association with the genital tuberculosis. In this situation, the infection is caused by mycobacterium tuberculosis (endemic areas of developing countries).

Based on the finding provides by the imaging studies, the differential diagnosis of this syndrome can be made with the following conditions: peritoneal carcinomatosis and appendicitis. The first has a different clinical presentation, with more nodules at the level of the peritoneum and a clear malignancy involving the ovaries. As for appendicitis, this can also be discussed as a further complication of the Fitz-Hugh-Curtis syndrome. Other conditions with which the differential diagnosis can be made are: ectopic pregnancy, viral hepatitis, pulmonary embolism and renal colic.

Treatment

These are the common courses of treatment taken for the patients suffering from the Fitz-Hugh-Curtis syndrome:

• Antibiotics
  • Elimination of the infection and improvement of the symptoms experienced by the patient
  • Recommended choices – ceftriaxone, azithromycin
• Anti-inflammatory medication
  • Purpose – reduction of inflammation and pain relief
  • Recommended choice – acetaminophen; codeine (in more severe cases)
• Laparoscopy
  • Performed on the adhesions, improving the refractory pain.

It is important to understand that the appearance of such complications can impair the fertility and also increase the risk for ectopic pregnancies in the future. When treating this syndrome, it is essential to treat the pelvic inflammatory disease as well (not just in the respective patient but also in all of the sexual partners that person has).

Prognosis

The prognosis of the Fitz-Hugh-Curtis syndrome is the same as for the pelvic inflammatory disease. Some patients might be asymptomatic, with the condition being discovered incidentally upon performing investigation for other health problems (for example, when trying to identify the reasons behind infertility).

Prevention

The Fitz-Hugh-Curtis syndrome, as well as the pelvic inflammatory disease, can be prevented by using protection when engaging in sexual intercourse. Maintaining excellent hygiene is essential, in order to reduce the risk of bacterial infections. Avoiding using public restrooms that are not clean is also a good idea, as it reduces the risk of catching a bacterial infection that can lead to such complications.

In regard to the sexual transmission, it is very important to talk to your partner about such problems the moment you have received the diagnosis. As it was already mentioned, the treatment of such problems does not concern only you but also all of the sexual partners you have had recently. Left untreated, the infection can be transmitted to other people. All sexual partners have to be treated for the infection and men in particular, as they can transmit the infection to other women (who present the risk of developing complications such as the Fitz-Hugh-Curtis syndrome).

In the recent years, there was a debate whether this syndrome should be presented as a problem related to the gynecologic area or the hepatic one. The latest studies have decided that this health problem belongs to the hepatic area, due to the more extensive affectation of the liver capsule.