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

This syndrome consists of right upper quadrant pain from perihepatitis (inflammation of the liver capsule or diaphragm) following the transabdominal spread of infection from pelvic inflammatory disease (PID). During the chronic phase, adhesions form between the anterior liver capsule to the anterior abdominal wall or diaphragm and they are classically descried as like a 'violin string'.¹

Epidemiology

This is said to affect between 4-14% of women who have PID but the immature anatomy of adolescents is thought to make them more susceptible and a figure of 27% is given.² The epidemiology tends to mimic that of PID, affecting women of reproductive age and often younger women; however, the condition has been reported in the absence of PID and in men.

Aetiology

Chlamydia trachomatis is now five times more common than the classically described Neisseria gonorrhoeae. This may represent a true change in epidemiology or it may be that culture techniques for chlamydia are now more readily available.³

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.

Presentation

There is both an acute and 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.⁴
• Pain may be referred to the right shoulder.
• Pain 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.⁵ The most important include:

• Ectopic pregnancy
• Pyelonephritis
• Cholecystitis
• Viral hepatitis
• Pulmonary embolism
• Renal colic
• Appendicitis

Often it is a diagnosis of exclusion.

Investigations

• Swabs should be taken for gonorrhoea and chlamydia
• Other techniques to diagnose genitourinary chlamydial infection are described in the separate article Chlamydial Genital Infection.
• 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.⁶ Enhanced CT may also be of value.⁷
• CXR may be helpful to exclude pneumonia, pulmonary embolism and air under the diaphragm.

Laparoscopy is often required for final diagnosis. Abnormality of the Fallopian tubes may be seen, with possible adhesions. During the acute phase, inflammation of the peritoneum and anterior liver capsule is seen and there may be an exudate that is grey and flaky or granular in appearance. The exudate has been described as like salt sprinkled on a moist surface.

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

• Appropriate antibiotics of appropriate duration to treat the PID. This may depend on the results of culture but the matter is discussed more fully in the article about PID.
• Analgesia may be required.
• It may be possible to divide some adhesions at laparoscopy.

Complications

There may be complications of PID, such as tubo-ovarian abscess. Future fertility may be impaired or there may be a predisposition to ectopic pregnancy.

Prognosis

Prognosis is generally as for PID. There may be no symptoms of Fitz-Hugh-Curtis syndrome and it is found incidentally at operation at a later date. It may also be found as an incidental finding when investigating infertility and, as such, it may also indicate tubal damage.⁸

Prevention

Prevention is as for PID.

Historical aspects

Fitz-Hugh and Curtis were not the first to describe the condition. In 1920 it was described by Stajano from Uruguay in an article in Spanish. Thomas Fitz-Hugh Jr was born in Maryland in 1894 and died in 1963. Arthur H. Curtis was born in 1881 and died in 1955. The two eponymous doctors do not seem ever to have worked together and their papers were published independently.

Document references

1. Moore Shepherd S, Pelvic Inflammatory Disease, eMedicine, Feb 2010
2. Peter NG, Clark LR, Jaeger JR; Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleve Clin J Med. 2004 Mar;71(3):233-9. [abstract]
3. Chlamydia - uncomplicated genital, Prodigy (May 2009)
4. Peter NG, Clark LR, Jaeger JR; Fitz-Hugh-Curtis syndrome: A diagnosis to consider in women with right upper quadrant pain.
5. Gatt D, Heafield T, Jantet G; Curtis-Fitz-Hugh syndrome: the new mimicking disease? Ann R Coll Surg Engl. 1986 Sep;68(5):271-4. [abstract]
6. van Dongen PW; Diagnosis of Fitz-Hugh-Curtis syndrome by ultrasound. Eur J Obstet Gynecol Reprod Biol. 1993 Jul;50(2):159-62. [abstract]
7. Nishie A, Yoshimitsu K, Irie H, et al; Fitz-Hugh-Curtis syndrome. Radiologic manifestation. J Comput Assist Tomogr. 2003 Sep-Oct;27(5):786-91. [abstract]
8. Sharma JB, Malhotra M, Arora R; Incidential Fitz-Hugh-Curtis syndrome at laparoscopy for benign gynecologic conditions. Int J Gynaecol Obstet. 2002 Dec;79(3):237-40. [abstract]

Internet and further reading

• Management of sexually transmitted infections and related conditions in children and young people, British Association for Sexual Health and HIV (2010)
• Sexually transmitted and other reproductive tract infections: A guide to essential practice, World Health Organization