Introduction

Brief overview of Fitz-Hugh-Curtis syndrome (FHCS)

Fitz-Hugh-Curtis syndrome (FHCS), also known as perihepatitis, is most commonly caused due to the intraperitoneal extension of pelvic inflammatory disease.¹ It is defined as an inflammation of the liver capsule, and there is no involvement of liver parenchyma with adhesion formation followed by right upper quadrant pain.²  The syndrome was first discovered and described by Curtis 1 in 1930 in the right upper quadrant of the abdomen as an acute gonococcal peritonitis. Later, in 1934, it was noticed by Fitz-Hugh 2 as a fibrous adhesion, or violet string-like appearance between the surface of the liver and the abdominal wall, majorly in patients with gonococcal pelvic inflammatory disease.³ According to a recent study, Chlamydia trachomatis is more commonly thought to be responsible for causing this particular condition. Finding violin-like strings along with the presence of causative organisms like Neisseria gonorrhoeae or Chlamydia trachomatis in the specimen collected from lesions of a hepatic capsule that have been detected with the help of laparoscopy or laparotomy confirms the presence of Fitz - Hugh- Curtis syndrome.³ FHCS exclusively affects females between the ages of 15 to 30 years of age.⁴ The incidence rates are reported to be around 4 to 14% of patients, and reports suggest that 27% of teenagers with salpingitis suffer from FHCS.⁵ 

It is always necessary to diagnose this condition prior in order to prevent long-term complications related to it. Also, there is a chance of misdiagnosis, which could further complicate the condition by unnecessary surgical procedures and delayed treatment.

Prognosis Overview

In medicine, the term ‘prognosis’ refers to the estimation of the likely outcome and degree of the improvement as well as the time required to reach that improvement in a medical condition. Predicting the degrees of improvement attained at various levels along the course of therapy.⁶ Time of diagnosis is crucial for effective treatment and prevention of long-term complications. Early detection of FHCS syndrome during the acute phase is very beneficial, when it is easier to treat, as it enables immediate use of the antibiotics in early stages. Delayed diagnosis might result in chronic complications like adhesions and persistent pain, etc. FHCS results in severe pain in the right upper quadrant, a classic clinical presentation that might be frequently misdiagnosed as appendicitis or cholecystitis.⁷ Research shows that those patients who are diagnosed early and undergo treatment immediately experience better results and fewer long-term complications in the future.⁸ 

Factors that influence prognosis include:

• Underlying conditions: conditions like pelvic inflammatory disease and other bacterial infections might greatly influence the prognosis. Additionally, the severity of the PID and the causative agent can also affect it, and complications like infertility, inflammation, and adhesions might result⁹
• Patient demographics: the patient's age is important here, as the younger woman who is less than 25 years old is more susceptible than the older woman. Moreover, having multiple sexual partners can raise the chances of UTIs, which can lead to FHCS¹
• Early diagnosis is always better for better prevention⁷
• Presence of complications

Long-Term Outcomes

Long-term complications are uncommon in Fitz-Hugh-Curtis syndrome. Some of them are infertility, pelvic inflammatory syndromes, chronic discomfort, intestinal blockage, and adhesion.¹⁰

• Chronic pain

Perihepatic inflammation and adhesion formation on the liver surface and on the abdominal wall are the major causes of severe pain and discomfort in the right upper quadrant region of the body. Any slight movement and even breathing could frequently elevate the pain and discomfort. Patients have even reported varied degrees of back pain and lower abdominal pain.¹ 

• Adhesion Formation

The major reason for the development of FHCS is gonococcal and chlamydial infection, which in turn result in pelvic inflammatory disease that spreads to the fallopian tubes. Scarring and adhesion formation occur when this condition spreads to fallopian tubes and other related organs. These result in intense pain and suffering for the patient.¹¹

Pelvic Inflammatory Disease (PID)

As it is known, pelvic inflammatory disease is a complication of FHCS, and it occurs due to the propagation of causative microorganisms from the cervix to the fallopian tubes through the endometrium. Microbes finally enter the peritoneal cavity through ascending infection.

Complications

• Infertility

30% of women suffering from pelvic inflammatory disease experience chronic pelvic pain due to adhesions, scarring, and inflammation. Periodic pelvic inflammatory disease occurrence can cause serious harm, like infertility, because the infection can affect the fallopian tubes, which finally causes blockage and loss of epithelial cells. Infertility caused by pelvic inflammatory disease, more likely manifested by chlamydia, is a very serious one.¹²

• Ectopic Pregnancy

The damage caused by the fallopian tube has also been linked with ectopic pregnancy secondary to PID. According to a study, the rate of ectopic pregnancy after PID is roughly around 7.8%, whereas without PID it is around 1.3%.¹²

• Psychosocial Impact

Patients suffering from FHCS suffer chronic pain, and this will impact their quality of life as they have to limit their daily activities or depend on others due to severe upper right quadrant pain. They also suffer depression and anxiety due to excruciating pain.

Management of Long-Term Outcomes

Treatment of Fitz-Hugh-Curtis syndrome depends on the management of pelvic inflammatory disease. The major goals of the treatment include alleviating the symptoms and disease progression and preventing long-term complications like ectopic pregnancy and infertility, etc.

Fitz-Hugh-Curtis syndrome is treated according to the symptoms. The primary course of treatment for people is antibiotic medication. In order to treat the underlying infections, different regimens of ofloxacin, metronidazole, tetracycline, doxycycline, and other antibiotics are prescribed. For pain management, analgesics like codeine and paracetamol are given.¹³ The gold standard for the treatment of pelvic inflammatory disease in FHCS is cefotetan 2 g intravenously given every 12 hours or cefoxitin  2 g  IV for every 6 hours combined with doxycycline 100 mg oral for every 12 hours. Laparoscopy is less bothersome than laparotomy, so it is employed to manage PID complications such as adhesions, which are present mostly in the perihepatic area, whose lysis helps in relieving symptoms.¹⁴ The best way to prevent FHCS is by preventing pelvic inflammatory disease from occurring. Also, PID can be prevented by using contraceptive measures during intercourse, avoiding douching, and getting regular checkups.

Care, Followup, and Monitoring

Follow-up care and monitoring for long-term prognosis and outcomes in Fitz-Hugh-Curtis syndrome (FHCS) are essential for ensuring effective management and minimising the risk of complications. 

Regular Monitoring of Symptoms

• Assessment of Pain: Patients have to be evaluated on a regular basis for any persistent or recurrent right upper quadrant pain, as this is an indication of any ongoing complications such as adhesions
• Monitoring for Complications: Regular follow-ups can help detect complications early, which include chronic pelvic pain, infertility, etc.
• Women with a history of FHCS should be counselled about the complications, such as fertility, and this might benefit from any future occurrences, and also regular gynaecological evaluations to monitor reproductive health are always helpful
• Effective management of FHCS often requires a multidisciplinary approach involving gynaecologists, primary care providers, pain specialists, and mental health professionals

Conclusion

Fitz-Hugh-Curtis syndrome (FHCS), also known as perihepatitis, is most commonly caused due to the intraperitoneal extension of pelvic inflammatory disease.¹ It is defined as an inflammation of the liver capsule, and there is no involvement of liver parenchyma with adhesion formation followed by right upper quadrant pain.² Finding violin-like strings along with the presence of causative organisms like Neisseria gonorrhoeae or Chlamydia trachomatis in the specimen collected from lesions of a hepatic capsule that have been detected with the help of laparoscopy or laparotomy confirms the presence of Fitz - Hugh- Curtis syndrome.³ FHCS exclusively affects females between the ages of 15 to 30 years of age.⁴ Early detection of FHCS syndrome during the acute phase is very beneficial, when it is easier to treat, as it enables immediate use of the antibiotics in early stages. Delayed diagnosis might result in chronic complications like adhesions and persistent pain, etc. Fitz-Hugh-Curtis syndrome is treated according to the symptoms. The primary course of treatment for people is antibiotic medication. The best way to prevent FHCS is by preventing pelvic inflammatory disease from occurring. PID can be prevented by using contraceptive measures during intercourse, avoiding douching, and getting regular checkups. Follow-up care and monitoring for long-term prognosis and outcomes in Fitz-Hugh-Curtis syndrome (FHCS) are essential for ensuring effective management and minimising the risk of complications.