What is Fitz-Hugh-Curtis Syndrome?
Fitz-Hugh-Curtis syndrome (FHCS), also known as perihepatitis, is a long-term complication that can occur from pelvic inflammatory disease (PID), an infection of a woman’s reproductive organs. It involves an inflammation of the liver’s outer covering, which can lead to the formation of bands of scar tissue causing pain in the upper right part of the abdomen. The diagnosis of this syndrome is usually made by looking directly into the abdomen using a procedure called laparoscopy or a type of surgery known as laparotomy. This allows doctors to see “violin string-like” scar tissues or extract a tiny section of the liver’s outer covering for tests and culture.
The syndrome was first described by Stajano in 1920 but not in English. In 1930, Curtis came across similar findings. During surgeries carried out on patients with unusual gallbladder pain, he found scar tissues between the liver’s front surface and the abdominal wall. He saw that while no other upper abdominal issues were apparent, changes in the fallopian tubes due to remaining gonorrhea bacteria were frequently noticed in these patients.
In 1934, Fitz-Hugh, Jr. reported similar instances where patients experiencing right upper abdomen pain were found to have unusual localized infections involving the liver’s front surface and the part of the peritoneal cavity near the diaphragm, another organ in the abdomen. After draining the fluids from these areas, smears taken from the fluid revealed specific bacteria. Today, however, it’s known that Fitz-Hugh-Curtis syndrome is not restricted to being caused by gonorrhea and can occur in both men and women.
What Causes Fitz-Hugh-Curtis Syndrome?
Fitz-Hugh-Curtis syndrome is a problem that can occur as a result of pelvic inflammatory disease, or PID, which is an infection of a woman’s reproductive organs. The germs that cause PID can spread in three main ways:
1. The first way is a “climbing” infection. This is when the germs start in the cervix or vagina and move up into the uterus, and then through the fallopian tubes, ending up in the area around the organs in the belly. This can lead to complications like inflammation of the uterus or fallopian tubes, an abscess (a pocket of pus) involving the ovary and fallopian tube, inflammation of the lining of the abdomen, and Fitz-Hugh-Curtis syndrome.
2. The second way is through the lymph system. This is a network of tiny tubes and nodes that help remove waste and fluids from the body and are part of the body’s immune system. The germs can infect the tissues around the uterus and spread through the lymph system. This might happen with something like an intrauterine device, which is a form of birth control that’s placed inside the uterus.
3. The third way is through the blood. The germs can get into the bloodstream and infect other parts of the body. This is how conditions like tuberculosis can spread.
Risk Factors and Frequency for Fitz-Hugh-Curtis Syndrome
PID, or an infection that travels upward affecting the genital tract, is most commonly found in sexually active women between 15 and 30 years old. In the United States, there are 750,000 cases of PID every year. A less common outcome of PID is FHCS, which affects about 4% of adolescents. Various organisms can be linked to FHCS, but the most frequent one is Chlamydia trachomatis.
Signs and Symptoms of Fitz-Hugh-Curtis Syndrome
Fitz-Hugh-Curtis syndrome (FHCS) typically affects women who are of childbearing age. Common symptoms include acute pain or long-term tenderness in the upper right area of the abdomen. Diagnosing FHCS can be complicated as upper right abdominal pain is a symptom associated with various conditions such as gall bladder inflammation, lung inflammation, kidney infection, abscesses under the diaphragm, or shingles. Recognizing FHCS requires an in-depth patient history and a heightened suspicion.
When a doctor suspects FHCS, they should consider risk factors related to the patient’s lifestyle and symptoms. These risk factors include:
- Being less than 25 years old
- First sexual encounter occurred before the age of 15
- Previous history of PID (Pelvic Inflammatory Disease)
- Use of IUD (Intrauterine Device) or oral contraceptives
- Recent IUD insertions
- Vaginal douching practices
- Patient’s exposure to new, multiple, or symptomatic sex partners
Pain in the upper right quadrant of the abdomen is due to inflammation around the liver and the forming of adhesions between the liver’s front surface and the abdominal wall. The pain usually worsens with movement and breathing, which can confuse it with other acute abdominal issues. Patients may also experience lower abdominal, pelvic, or back pain varying in severity. Other symptoms include fever, chills, nausea, vomiting, vaginal discharge, pain during intercourse, painful urination, cramping, and bleeding after intercourse.
A physical examination for FHCS may reveal:
- Vital signs: Fever above 38.3 C (100.9°F)
- Abdominal exam: Tenderness in the right upper quadrant, rebound tenderness, guarding, or a silent abdomen
- Pelvic exam: Tenderness during cervical motion, adnexal tenderness, uterine compression tenderness on bimanual examinations. The doctor may also observe signs of a lower genital tract infection such as cervical mucus discharge and cervical friability (easy bleeding) on speculum examination.
Testing for Fitz-Hugh-Curtis Syndrome
If you’re being evaluated for Fitz-Hugh-Curtis syndrome (FHCS) or pelvic inflammatory disease (PID), your doctor will likely do a variety of tests.
For lab tests, they might start with a pregnancy test. This can help decide which antibiotic to use for treatment and also show if an ectopic pregnancy might be the issue. A complete blood count (CBC) is often done to look for high levels of white blood cells. Although this can be a sign of infection, less than half of women with PID have significantly raised white blood cell levels. Other lab tests might include blood cultures, and a complete metabolic panel to check your kidney and liver function and electrolyte levels.
Your doctor might also test your vaginal secretions for white blood cells and bacteria such as chlamydia and gonorrhea. They might also test you for syphilis, hepatitis B and C, and HIV. A urinalysis (urine test) might also be done.
Imaging tests might also be done, starting with a computerized tomography (CT) scan. This scan can provide detailed images of your lower abdomen and pelvis. It might show inflammation around your liver (perihepatic enhancement) and infiltrations of fat in your pelvic cavity. Other signs associated with PID could show up, such as pus-filled fallopian tubes (pyosalpinx), an abscess in your fallopian tube or ovary, and excess fluid in your pelvic cavity.
Another useful test is a transvaginal ultrasound, which creates images using sound waves. This can be particularly helpful if it’s not clear if you have PID. This test can also show a fluid-filled fallopian tube (hydrosalpinx), an inflamed lining of your womb (endometritis), an abscess in your fallopian tube or ovary, inflammation of your ovaries (oophoritis), and an ectopic pregnancy.
An MRI can be also done to create detailed images of your lower abdomen and pelvis. This test might show an abscess in your fallopian tube or ovary, swollen fallopian tubes, or excess fluid in your pelvic cavity.
Laparoscopy, which involves a surgeon making a small incision and inserting a thin, lighted tube, is considered the best way to diagnose FHCS and PID. This test allows the doctor to see if your fallopian tubes are swollen and if there’s an ectopic pregnancy or an abscess in your fallopian tube or ovary. FHCS can be diagnosed by looking for adhesions (bands of scar-like tissue) between your diaphragm and liver, or between your liver and the front wall of your abdomen.
Lastly, a sample of your womb’s lining might be taken (an endometrial biopsy), which could indicate endometritis.
Treatment Options for Fitz-Hugh-Curtis Syndrome
Treating Hybrid Female Chronic Syndrome (HFCS) is closely tied to treating Pelvic Inflammatory Disease (PID). The main goals of these treatments are to relieve symptoms, get rid of the infection, and reduce the risk of long-term issues like infertility or ectopic pregnancy – a dangerous condition where a fertilized egg grows outside the uterus.
The diagnosis of PID can be difficult, and the consequences of not treating it can be severe. Consequently, the Centers for Disease Control and Prevention (CDC) advises doctors to treat suspected cases of PID aggressively. Antibiotics can successfully treat up to 75% of cases. Most people with PID can be managed outside the hospital with antibiotic treatments. These treatments should aim to target the most common bacteria causing the infection.
The exact types and combinations of antibiotics used can vary based on the suspected cause of the infection and the patient’s individual circumstances. The usual choice of medication has proven to be effective against gonorrhea and chlamydia, two bacteria commonly associated with PID.
Hospitalization may be necessary in some cases, such as:
* If diagnosis is uncertain.
* If the patient is pregnant.
* If the patient is seriously ill.
* If a pocket of infection (abscess) is detected in the pelvic region in imaging.
* If the patient cannot tolerate food or drink by mouth.
* If the patient has weakened immunity.
* If symptoms don’t improve 72 hours after starting treatment.
If fever, chills, or pain during a pelvic examination persist for longer than 72 hours after starting treatment, a reevaluation is necessary. In some cases, this could involve a surgical procedure known as diagnostic laparoscopy – a minimally invasive surgical process where a thin tube with a camera is inserted into the abdomen through a small incision. This procedure allows the surgeon to visually check the organs in the abdomen and pelvis. It may also involve procedures to get rid of scar tissues that might be causing symptoms, drain abscesses, or, if needed, remove one of the structures next to the uterus. A more invasive surgical procedure (laparotomy) might be necessary for patients who experience a medical emergency, such as a ruptured abscess, or for those who cannot undergo the laparoscopic procedure.
What else can Fitz-Hugh-Curtis Syndrome be?
Fitz-Hugh-Curtis Syndrome can look a lot like other diseases. These may include:
- Ectopic pregnancy (a pregnancy occurring outside the womb)
- Cholecystitis (inflammation of the gallbladder)
- Viral hepatitis (an infection causing liver inflammation)
- Renal colic (a type of pain caused by kidney stones)
- Pyelonephritis (a type of kidney infection)
- Pulmonary embolism (a blood clot in the lungs)
- Appendicitis (inflammation of the appendix)
What to expect with Fitz-Hugh-Curtis Syndrome
The future outlook for female genital infections, known as FHCS, is not well-documented. However, these infections tend to respond well to antibiotics. In a recent study comparing two different antibiotic treatments for a type of these infections not caused by chlamydia, only one patient in each treatment group did not respond to treatment.
Possible Complications When Diagnosed with Fitz-Hugh-Curtis Syndrome
One common problem for people with Fitz-Hugh-Curtis syndrome is that it can lead to difficulty conceiving a child. Additionally, it is rare but possible for a bowel obstruction to occur because of the formation of abnormal tissue bands in the abdominal cavity.
Possible Complications:
- Difficulty in conceiving a child
- Rare instances of bowel obstruction due to formation of abnormal tissue bands in the abdominal cavity