Overview of Fitz-Hugh-Curtis Syndrome (FHCS)

Fitz-Hugh-Curtis Syndrome also known as perihepatitis is a rare condition that is most commonly and almost exclusively seen in women. This condition is characterized as inflammation of the membrane lining of the stomach known as peritoneum, and the tissues surrounding the liver perihepatitis. These inflammations reach the tissue around the liver creating violin-string-like, sticky strands. The diaphragm is also affected which causes difficulty  breathing.^1,5

Understanding the complications associated with Fitz-Hugh-Curtis Syndrome (FHCS) is crucial for effective management and improved patient outcomes. Recognizing and addressing complications early can help prevent further health problems, optimize treatment strategies, and provide better support for individuals affected by FHCS. Awareness of these complications ensures that healthcare providers can offer comprehensive care and improve overall patient well-being.

Symptoms

Common symptoms noted with Fitz-Hugh-Curtis Syndrome:

• Pain or tenderness that is acute and noted at the upper part of the right side quadrant
• Pain worsens with breathing or with any movement
• Fever greater than 38.3 C
• Chills
• Nausea, vomiting
• Headaches
• Malaise  
• Vaginal discharge
• Pain during intercourse: Dyspareunia
• Painful urination: Dysuria
• Postcoital bleeding
• Lower abdominal, pelvic, or back pain may also be noticed²

Causes and risk factors

Fitz-Hugh-Curtis Syndrome is a complication that follows pelvic inflammatory disease (PID), which is an infection of the upper genital tract most often caused by Neisseria gonorrhoeae and Chlamydia trachomatis. Additionally, other types of bacteria can also cause this condition. This is a condition noted in women, The rate is higher in adolescents due to their  reproductive organs being less mature so they are easily infected however this condition is rare in  women of child bearing age.^1,5

Risk factors include: 

• Having multiple sexual partners 
• Having unprotected sex
• A previous history of sexually transmitted infections
• History of pelvic inflammatory disease 
• A history or use of an intrauterine device, which is used as a contraception
• Vaginal douching is also known to be a possible risk factor
• Being under the age of 25 and being a female is also a risk factor as mentioned above since this condition is common in women who have less mature reproductive systems

Complications Associated with Fitz-Hugh-Curtis Syndrome

• Infertility: The most commonly known complication of  Fitz-Hugh-Curtis Syndrome is infertility. It is a disease of the male or the female reproductive system due to which the couple is unable to achieve a pregnancy even after 12 months or more of regularly unprotected sexual intercourse³ 
• Fertility is affected as an indirect cause of pelvic inflammatory disease which is the main cause of Fitz-Hugh-Curtis Syndrome, as well as infertility. This is because pelvic inflammatory disease causes formation of scar tissue which obstructs and blocks the fallopian tube and this acts as a hindrance during fertilization and prevents it from occurring⁵
• Bowel obstruction: Bowel obstruction is a mechanical or functional obstruction of the large or small intestine⁴
• Endometritis: This is a condition where the tissue similar to that of the uterine lining is found outside of the uterus⁶
• Salpingitis: Inflammation of the fallopian tubes due to bacterial infection is known as salpingitis. It is more common in sexually transmitted diseases such as gonorrhoea and chlamydia and this is also a common cause of infertility as it damages the fallopian tubes⁷ 
• Tubo-ovarian abscess: An infectious adnexal mass (tumour) also another consequence that follows pelvic inflammatory disease⁸
• Peritonitis: When the tissues that line and cover the inner wall of the abdomen and abdominal organs are inflamed it is known as peritonitis¹⁰
• Chronic pain is also a long term complication of Fitz-Hugh-Curtis Syndrome²
• Ectopic pregnancy: an ectopic pregnancy occurs due to the implantation of the fertilised egg outside of the uterus⁹

Diagnosis 

Diagnosis of Fitz-Hugh-Curtis Syndrome is noted to be tough as it can present with non-specific symptoms which may lead to delay in diagnosis and may resemble many other conditions.

Laboratory exams 

• A pregnancy test will be performed to rule out the chances of an ectopic pregnancy
• Blood tests that check your complete blood count will also be performed in order to assess for increase in your white blood cell count that could show any indicated signs of infection, however it is not a characteristic finding and is only noted in 50% of women
• Electrolyte, renal, or hepatic derangements are checked with a complete metabolic panel
• A speculum exam may be performed during your physical exam which will also include collecting of vaginal secretions to assess for leukorrhea
• Cultures will be ordered for chlamydia along with gonorrhoea

Other tests 

• CT scan to visualise perihepatic enhancement in the arterial phase, with a majority of patients also showing pelvic fat infiltration, pyosalpinx, tubo-ovarian abscess, and fluid collection in the pelvic cavity can also be seen in pelvic inflammatory disease
• Transvaginal ultrasonographic scanning is used in cases where the clinical picture of pelvic inflammatory disease may not be as clear
• MRI can be used to note tubo-ovarian abscess, edematous tubes, or free pelvic fluid collections
• Laparoscopy is the gold standard for diagnosing Fitz-Hugh-Curtis Syndrome and pelvic inflammatory disease as it can easily visualise the adhesions between the liver and the diaphragm. In the setting of PID, laparoscopy can show edema with exudates on tubal surfaces, ectopic pregnancy, or tubo-ovarian abscess²

Differential diagnosis 

As this condition has non specific symptoms other diseases such as ectopic pregnancy, cholecystitis, viral hepatitis, renal colic, pyelonephritis, pulmonary embolism, appendicitis would also be considered.²

Management

Fitz-Hugh-Curtis Syndrome is treated in association with pelvic inflammatory disease, and the main aim of treatment is to improve the symptoms and reduce them, eliminate the infection that is present, reduce risk of the mentioned complications from occurring or any of the long term sequelae. The primary focus would be to reduce complications as the diagnosis of these conditions may take longer due to the unclear signs and symptoms which leads to delayed diagnosis and in turn delay in the management as well, this significantly increases the chances of being prone to developing complications as the disease is diagnosed at a progressed stage.

Antibiotics are successful in two thirds of the cases which is 75%. This antibiotic treatment is more focused on the commonly noted organisms chlamydia trachomatis, and Neisseria gonorrhoeae, as well as gram-negative organisms, anaerobes, and streptococci. These antibiotics include ceftriaxone, doxycycline, and metronidazole.

The patients are usually managed and can be treated as an outpatient, however in cases of uncertainty in diagnosis, pregnancy, severe cases and abscess noted in the pelvic area on imaging the patient is advised to be hospitalised and managed as an inpatient.

It is important to note that patients that do not improve after 72 hours are considered for reevaluation and might go through for a surgical intervention.²

Prognosis 

Antibiotics work in most of the cases which gives this condition a good prognosis as they respond well to antibiotics, however diagnosis can be difficult.²

FAQs 

What is Fitz-Hugh-Curtis Syndrome (FHCS)?

Inflammation of the liver capsule and surrounding tissues, frequently caused due to pelvic inflammatory disease, or PID.

What typical FHCS symptoms are present?

Pain in the shoulder, right upper abdomen, and generalised stomach discomfort are typical symptoms.

How is FHCS diagnosed?

A combination of the patient's medical history, physical examination, imaging tests (such as CT or ultrasound), and occasionally laparoscopy are used to make the diagnosis.

What are the main reasons why FHCS develops?

Pelvic inflammatory disease (PID), which frequently arises from STDs, is the primary cause of FHCS.

What are the treatment options for FHCS?

Antibiotics are typically used to treat underlying infections, along with pain management and, in rare cases, surgical intervention if complications arise.

How does FHCS affect long-term health?

Chronic pain and possible infertility are two long-term health implications that could arise depending on the severity and treatment of the illness.

Can FHCS result in additional problems?

Yes, complications can include chronic pain, adhesion formation, and issues related to reproductive health.

How can FHCS be prevented?

Addressing and treating pelvic inflammatory illness as well as engaging in safe sexual behaviour to lower the risk of STDs are key components in preventing FHCS.

What should patients know about managing FHCS?

In order to manage and minimise consequences, patients should understand how important it is to adhere to treatment regimens, keep an eye on their symptoms, and schedule routine follow-up visits.

Is FHCS a prevalent illness?

FHCS is not as frequent as other pelvic inflammatory disease complications, but it can occur in individuals with PID, particularly those with severe or recurrent infections.