Introduction

Fitz-Hugh-Curtis syndrome (FHCS) is a rare condition that occurs as a complication of pelvic infection.¹ This condition occurs when the infection spreads from your pelvic area to the liver, causing pain in the upper right side of your abdomen.¹ Since the symptoms of FHCS can be similar to several other health issues, an accurate diagnosis of Fitz-Hugh-Curtis syndrome is crucial.² Correct diagnosis helps in appropriate treatment by medical professionals and can significantly impact your healing process. Even though laboratory testing is necessary to diagnose this condition, the results may not always be accurate. Therefore, to get accurate pictures and aid in the diagnosis of FHCS, healthcare providers use imaging techniques like ultrasonography, CT scans, and MRIs.¹ In this article, we will discuss the imaging techniques used for accurately diagnosing this syndrome.

Overview of fitz-hugh-curtis syndrome

Fitz-Hugh-Curtis syndrome, also known as perihepatitis syndrome, is a condition where the liver capsule (a thin layer of tissue surrounding your liver) and the peritoneum (lining of your abdomen) become inflamed.² Sometimes, this inflammation may also impact the diaphragm (a muscle that helps you breathe).² 

This condition appears predominantly in the female population and occurs as a complication of pelvic inflammatory disease (PID), which is a bacterial infection of the female reproductive tract, including the uterus, fallopian tubes, and ovaries. FHCS occurs when this infection spreads to your liver through the blood or lymphatic system. Once the inflammation reaches the liver capsule, it results in sticky, violin-string-like strands that bind your liver capsule to the interior of your abdomen or diaphragm.^1,2,3

 The most common causes of PID infection are sexually transmitted diseases like chlamydia (caused by the bacterium Chlamydia trachomatis) and gonorrhea (caused by Neisseria gonorrhoeae). Fitz-Hugh-Curtis Syndrome affects 4–14% of women with PID. However, because of their increased susceptibility to infections, adolescents with PID are reportedly more likely to acquire FHCS.^1,2

What are the symptoms?

Fitz-Hugh-Curtis Syndrome often causes:

• Intense, sharp pain in the upper right side of your abdomen
• Pain spreading to the right shoulder and inside the right arm
• Increased pain with movement
• Extreme tenderness in the upper right abdomen
• Fever and chills
• Night sweats
• Vomiting and nausea
• Headaches
• Hiccups
• Overall feeling of being unwell (malaise)

Sometimes, you may also have PID-related symptoms. These include:

• Vaginal discharge
• Lower abdominal pain that may occur before, after, or at the same time as upper abdominal pain¹

What are the complications?

Fitz-Hugh-Curtis syndrome can lead to several complications, including:

• Endometriosis
• Salpingitis
• Tubo-ovarian abscess
• Pelvic peritonitis
• Infertility
• Chronic pain
• Bowel obstruction
• Ectopic pregnancy²

Diagnosis of fitz-hugh-curtis syndrome

Sometimes, the correct diagnosis of Fitz-Hugh-Curtis syndrome can be difficult as its symptoms mimic those of several other diseases. Some of these diseases with similar symptoms are:

• Ectopic pregnancy (pregnancy that develops outside the uterus)
• Cholecystitis (inflammation of the gallbladder)
• Viral hepatitis 
• Renal colic (pain from kidney stones)
• Kidney infection
• Pulmonary embolism (blockage in the lungs caused by a blood clot)
• Appendicitis²

To rule out these related disorders and make a proper diagnosis of FHCS, your doctor may conduct a number of laboratory tests. These tests include:

Pregnancy test: if the test results are positive, it helps doctors rule out an ectopic pregnancy and avoid prescribing certain antibiotics.

Complete blood count: checks for higher white blood cell levels to identify possible infections.

Comprehensive metabolic panel: checks your blood for problems with your electrolytes, kidney function, and liver function, as FHCS might influence them.

Vaginal secretions: Examining vaginal secretions can assist in detecting infections, such as discharge that isn't normal (leukorrhea), and could indicate PID.

Tests for sexually transmitted infections: this is done in order to screen for infections with gonorrhea and chlamydia, which can result in FHCS.³

Imaging techniques for diagnosis

Your doctor may perform imaging tests to accurately diagnose FHCS. This is particularly helpful when determining the exact cause of pelvic symptoms is challenging.¹

Ultrasound

Many of us or our loved ones have had ultrasound scans at some point in our lives. Oftentimes, ultrasound is the first step in the diagnosis of FHCS and can provide crucial details.¹ Sound waves are used in an ultrasound scan to produce pictures of your internal organs. When a transducer (tiny probe) is placed on the skin, it emits sound waves that bounce off surrounding tissues and come back to the probe, and a picture is created using these echoes.⁴ The doctor looks at these images to look for abnormalities or indications of FHCS.

Transvaginal ultrasound 

A transvaginal ultrasound is a special type of ultrasound that helps to get clear images of the pelvic area and liver.¹ Here, the transducer is gently inserted into the vagina to create images of your pelvic organs on a screen.⁵ 

The characteristics of an ultrasound scan that may reveal if you have FHCS or PID include:

• Thickened liver capsule: The liver capsule might appear thicker than usual, which might indicate inflammation
• Three-layer appearance: The liver capsule may seem like three separate layers at times. An inflammation of the liver capsule and surrounding tissues, such as the abdominal wall and diaphragm, may be indicated by this pattern. It may suggest FHCS, especially if there are no other obvious causes for the pain
• Wider right anterior extrarenal space: a particular area that is close to the right kidney is measured. In people with FHCS, this area could be broader than typical
• Ascitic Fluid: fluid accumulation in the space around the liver (hepatorenal space) and near the spleen
• Adhesions (bands of scar tissue) between the liver and the abdominal wall
• Hydrosalpinx: fallopian tubes filled with fluid, which might indicate inflammation
• Pyosalpinx: pus-filled, infected fallopian tubes, which suggests a more serious illness
• Endometritis: inflammation of the uterus lining
• Tubo-Ovarian Abscess: a pocket of infection near the ovaries and fallopian tubes
• Oophoritis: inflammation of the ovaries
• Ectopic pregnancy^1,6,7

X-ray

To help with the FHCS diagnosis, your doctor could take a chest or stomach X-ray. It can help rule out other probable conditions and reveal inflammation surrounding the liver.¹

CT scan

Sometimes, further imaging tests, such as a computed tomography (CT) scan, are used by doctors to confirm the diagnosis. CT scans are advanced imaging tests that produce highly detailed images of the inside of your body using X-rays and a computer.^3,8

Findings from the CT scan that are indicative of FHCS in the pelvic area include:

• Tubo-ovarian abscess
• Pyosalpinx
• Fluid collection 

Indications in the perihepatic area ( area around the liver) include:

• Inflammatory stranding (inflammation resulting in streaks or bands of swelling) and fluid along the right paracolic gutter (space on the right side of your abdomen) and the perihepatic region (area around the liver)
• Hepatic capsular enhancement: The outer layer of the liver might appear brighter on the scan due to inflammation
• Gallbladder wall thickening: If the gallbladder wall appears thicker than usual, it may be indicative of inflammation
• Pericholecystic inflammatory change: Inflammation around the gallbladder, seen as changes in the tissue surrounding it
• Transient hepatic perfusional abnormalities: Temporary changes in how blood flows through the liver^3,8

PET-CT scan

PET-CT scan is an advanced imaging technique that merges the detailed imaging of computed tomography with positron emission tomography (PET). This technique has been recently reported for the diagnosis of FHCS, particularly helpful for evaluating nonspecific abdominal and inflammatory symptoms.⁹

MRI

An MRI (magnetic resonance imaging) scan is an imaging technique that uses strong magnets and radio waves to create detailed images of the inside of your body.¹⁰ Especially when a PID diagnosis is unclear, MRI is frequently employed.

MRI can indicate:

• Edematous fallopian tubes: An MRI can reveal whether the fallopian tubes are swollen and fluid-filled. An infection or inflammation is indicated by the accumulation of free fluid in the pelvic region and the area around the liver
• Tubo-ovarian abscess
• Increased brightness around the liver’s outer layer or liver capsule indicates inflammation¹⁰

Other procedures

In addition to imaging tests, doctors can use other procedures to diagnose FHCS. These are:

Laparoscopy: This is a key procedure for diagnosing FHCS and PID. Here, a small cut is made in the tummy to allow a tiny camera to be inserted in order to examine the organs up close. Features like swelling and fluid in the fallopian tubes, ectopic pregnancy, and tubo-ovarian abscesses can be revealed from this. Doctors also look for scar tissue (adhesions) between the liver and nearby areas.³

Endometrial biopsy: In order to assist in diagnosing endometritis, a tiny sample of the uterine lining is removed and examined for inflammation.³

Summary

• Fitz-Hugh-Curtis syndrome is a rare complication of pelvic inflammatory disease, characterised by inflammation of the liver capsule
• It might be challenging to diagnose Fitz-Hugh-Curtis syndrome because of symptom overlap with various diseases, such as cholecystitis and ectopic pregnancy symptoms
• Imaging techniques are used for accurately diagnosing this condition. These include ultrasound, CT scans, and MRI to detect characteristic symptoms
•  The features detected using these imaging techniques include a thickened liver capsule, inflammatory changes around the liver, fluid collections in the perihepatic region, and possible abscesses in the pelvic area
• Having an early and accurate diagnosis upon experiencing symptoms is crucial for effective treatment and recovery