This article will deepen your understanding of Fitz-Hugh-Curtis Syndrome (FHCS). Whether you're a healthcare advisor, a medical student, or someone generally concerned about this condition, here you can get the necessary information required to grasp the insights of this syndrome. 

Fitz-Hugh-Curtis Syndrome (FHCS) is a condition characterised by inflammation of the liver capsule that primarily affects women, and is often associated with pelvic inflammatory disease (PID). The main agents of FHCS are caused by bacterial infections, specifically Chlamydia trachomatis and Neisseria gonorrhoeae, also associated with PID.¹ The pivotal risk factors for FHCS consist of being sexually active and having any history of PID or sexually transmitted infections (STIs). Inflammation in the liver capsule occurs when these bacteria spread to the upper abdomen, initiating hepatitis.¹ Understanding these factors is crucial for both the prevention and management of this condition.² 

Aetiology of fitz-hugh-curtis syndrome (FHCS)

Fitz-High-Curtis syndrome (FHCS), also referred to as perihepatitis, is a rarely occurring syndrome caused by the inflammation of the peritoneum (membrane lining the stomach), which expands to influence the surrounding tissue of the liver.¹ This syndrome has strong associations with perihepatitis, a state where the liver capsule is inflamed and is frequently linked to pelvic inflammatory disease (PID).³ FHCS is thought to be a direct complication of PID, where the associated microbes can travel in various ways.² The pathophysiology for this syndrome includes bacteria rising through the cervix and into the peritoneal cavity, lymphatic spread via positive nodes, or through other metastasis routes such as hematogenous spread, leading to the characteristic inflammation seen in FHCS.^2,4

What causes fitz-hugh-curtis syndrome (FHCS)?

For Fitz-Hugh-Curtis Syndrome, perihepatitis is likely triggered by bacterial infections.⁵ The most common strains of bacteria are known as Chlamydia trachomatis and Neisseria gonorrhoeae, both are sexually transmitted pathogens that play a part in the pathogenesis of this syndrome.^3,5 These pathogens are also responsible for pelvic inflammatory disease (PID).² Although FHCS can be polymicrobial and involve multiple bacterial strains rather than a result of one.⁶

Potential routes for these bacterial strains to travel and ignite inflammation involve migration from the pelvic organs to the Glisson’s capsule of the liver, usually through the peritoneal cavity.⁷ This spread results in localised inflammation, which can cause adhesions to form between the liver capsule and the surrounding peritoneal surfaces, stimulating the characteristic right upper quadrant pain of the stomach, a common symptom of FHCS.³ Interestingly, while the liver capsule is affected, the liver parenchyma (the functional tissue of the liver) remains unaffected, which means liver function tests may not always be significantly altered in FHCS patients.⁸

Some research suggests that an autoimmune reaction may play a role in igniting FHCS, where the body mistakenly attacks its own cells after being infected with either C. trachomatis or N. gonorrhoeae.¹ Additionally, patients with gonorrhoeal infections have sometimes shown unusual liver test results, such as increased serum alkaline phosphatase concentrations, further complicating the clinical picture.⁹ However, despite these flaws, FHCS is still recognisable from other hepatic conditions.² 

Risk factors of FHCS

Sexual behaviour is a major contributor to the development of Fitz-Hugh-Curtis Syndrome (FHCS), a condition that is rare but has serious consequences from sexually transmitted infections.⁶ The primary strains of bacteria associated with FHCS, namely, Neisseria gonorrhoea and Chlamydia trachoma, are sexually transmitted. Hence, controlling the risk factors correlated with these pathogens could also prevent the manifestation of this syndrome.¹⁰ 

Engaging in high-risk sexual behaviours increases the likelihood of contracting these infections. This includes having multiple or new sex partners, engaging in sex with someone who has or has had an STI, a history of STIs and inconsistent condom usage. Moreover, behaviours such as having sex under the influence of drugs or alcohol can further elevate this risk.¹⁰

Individuals with a history of pelvic inflammatory disease (PID) are also vulnerable to developing FHCS.² PID often arises from untreated STIs and is commonly associated with autoimmune disorders; hence, immunocompromised states could also be a potential risk.^11,12

Certain demographic factors could also influence the susceptibility to FHCS. Young people, particularly those under the age of 25, are at higher risk of developing STIs [13]. Women, especially those of childbearing age, are more susceptible to developing FHCS.² Public health data reveal that risk communities, including those from a Black Caribbean background or those living in socially deprived areas, are disproportionately affected by STIs, making them more vulnerable to FHCS.¹³

Additionally, the usage of intrauterine devices (IUDs) or any oral contraceptives either currently or in the past has been identified as a contributing risk factor too.²

Symptoms of fitz-hugh-curtis syndrome (FHCS)

There are various distinct symptoms that FHCS exhibits. However, some patients were asymptomatic, even though perihepatic adhesions were detected using laparoscopy.³

Fitz-High-Curtis syndrome is primarily characterised by a sudden onset of acute and sharp pain in the upper right quadrant of the abdomen or below the ribs, often radiating to the right shoulder and arm.³ This pain is typically exacerbated by movement, making it difficult for patients to find relief.¹

Tenderness in the upper right quadrant, accompanied by peritoneal irritation, is another hallmark of FHCS.⁷ Patients may also experience systemic symptoms such as fever, chills, lower abdominal pain, vomiting, and abnormal vaginal discharge, which are common in pelvic inflammatory disease (PID) but may also appear in FHCS.¹ In some cases, patients report headaches and hiccups, adding to the complexity of the clinical presentation.¹⁴

Differential diagnosis 

Diagnosing FHCS can be challenging due to its symptoms overlapping with other abdominal conditions, such as appendicitis, cholelithiasis and pancreatitis.³

Diagnosis of fitz-hugh-curtis syndrome (FHCS)

 A patient’s full medical history and symptoms examination would be the first step in diagnosing FHCS.² Screening tests for STIs, especially for gonorrhoea and chlamydia, would also commonly take place to confirm the presence of these pathogens.¹

To further evaluate the presence of FHCS, laboratory tests would be performed to consider other diseases, to assess blood counts and metabolite counts.^2,9 Liver function tests may be obtained to ensure no damage has occurred to the liver itself.¹⁵

Imaging plays a huge role in FHCS diagnosis. The development of CT scans became a useful radiology tool for detecting and inspecting FHCS.³ This also allows the visibility of accentuated perihepatitis along the anterior liver surface or any fluids that have ended up in the pelvic cavity.^2,7 However, laparoscopy evaluation is the most common and reliable approach for diagnosis of FHCS, where it allows direct visualisation of ‘violin-string’ adhesions, located between the abdominal wall or diaphragm and the liver capsule.^2,9

Treatment and management of FHCS

Managing PID and treating FHCS is the main goal, to prevent long-term effects such as pregnancy implications, and eliminate both symptoms and the infection.² The first resort may be a course of antibiotics to minimise symptoms or treat Fitz-Hugh-Curtis syndrome, which has shown to be mostly effective.^2,3 Antibiotic therapy is used with the intention of eradicating all microbes that would have initiated the disease as this syndrome can be polymicrobial, hence strains such as N. gonorrhoea and C. trachomatis are targeted.^2,6 A commonly prescribed antibiotic to treat FHCS is intravenous ceftriaxone or azithromycin.^2,9 Personalised antibiotic treatments may be provided after initial examinations as well.²

If any symptoms continue even after days of treatment, this could be an indication for surgical intervention, particularly when adhesions cause significant complications or discomfort.²

Finally, follow-up measures will take place until all symptoms have been eradicated, and the tests are negative for FHCS.² Preventive measures and advice would be provided to help reduce the recurrence risk of this syndrome.²

FAQs

What can cause fitz-hugh-curtis syndrome?

Bacterial infections are the main cause; however, the key risk pathogens include Chlamydia trachomatis and Neisseria gonorrhoeae which travel and spread in the body.

How do I know I am experiencing fitz-hugh-curtis syndrome symptoms?

The most common symptoms include acute right upper quadrant pain in the stomach, but also more subtle symptoms such as fever.

Are there any complications for fitz-hugh-curtis syndrome?

The main complication is infertility, emphasising the importance of detecting and treating this syndrome as quickly as possible.²

How is fitz-hugh-curtis syndrome diagnosed?

Diagnosis involves various examinations and laboratory tests to detect STIs, alongside imaging techniques such as ultrasound or CT scans.

Summary

Fitz-Hugh-Curtis Syndrome is a condition characterised by inflammation of the liver capsule, often resulting from bacterial infections associated with PID. This syndrome mainly affects women of reproductive age from sexually transmitted diseases.³ The main risk factors include multiple sexual partners or any sexual activity, and a history of PID or STIs. Effective diagnosis involves several laboratory tests and imaging tools, alongside a full medical history examination. Treatment will typically include a course of antibiotics. Understanding these aspects is crucial for prevention in the future and successful management of FHCS.