Introduction

What is Fitz-Hugh-Curtis syndrome?

Fitz-Hugh-Curtis syndrome (FHCS) is a rare disease that occurs as a complication of pelvic inflammatory disease (PID). It is also known as perihepatitis. In FHCS, inflammation of the liver capsule occurs with the formation of adhesions and swelling of tissues around the liver, which leads to pain in the upper quadrant of the abdomen.

PID is an infection of the female reproductive organs in which bacteria spread from the vagina to the internal reproductive organs, which is caused by sexually transmitted infections like chlamydia or gonorrhoea. It causes inflammation of the uterus, fallopian tube, cervix, or vagina.¹

Epidemiology

Fitz-Hugh-Curtis syndrome (FHCS) is an uncommon complication of PID involving around 10% to 15% of women.¹ It affects sexually active women between the ages of 15 and 30 because they are more susceptible to infection. Many organisms are involved in the spread of FHCS. Chlamydia trachomatis and Neisseria gonorrhoeae are the most common pathogens. It is more common in the population with a higher rate of sexually transmitted infections (STIs).

Aetiology/causes

Fitz-Hugh-Curtis syndrome is a complication of PID. Some of the key factors involved in the spread of pathogens are:

• The pathogens from the cervix and vagina can ascend into the thin layer of the uterus through the fallopian tube and into the peritoneal cavity, which causes endometritis, tubo-ovarian abscess, pelvic peritonitis, and FHCS²
• Spread through the bloodstream, also called haematogenous spread, such as tuberculosis
• Spread of pathogens from the pelvic region to the liver capsule through the lymphatic system

Pathophysiology

The pathophysiology of FHCS includes the spread of infection from the pelvic region to the liver capsule, which causes inflammation and adhesion of tissues.^3,4 The spread of pathogens is as follows:

• It begins with PID, which is caused by chlamydia and gonorrhoea, and the infection ascends from the pelvic region to the upper reproductive organs
• When the pathogen crosses beyond the reproductive organs, it reaches the liver capsule through the bloodstream, peritoneal cavity, or lymphatic system, which causes the inflammation of Gillson’s capsule and inflames the fibrous tissues surrounding the liver
• The inflammation of the liver, also called perihepatitis, causes adhesion between the liver capsule and the diaphragm. Because of its appearance, the adhesion between the diaphragm and liver capsule is called violin string adhesion³

Clinical manifestations

This inflammation and adhesion cause severe pain in the upper quadrant of the abdominal cavity, which is associated with the FHCS. Sometimes, despite having significant pain, the tissue of the liver remains unaffected.⁵

Symptoms

Fitz-Hugh-Curtis syndrome is characterised by severe and sudden pain in the upper right part of the abdomen, just below the diaphragm. Sometimes pain may spread to the right arm and shoulder, which makes the shoulder stiff. The movement makes it more painful.⁶

Some other symptoms associated with FHCS and PID include:

• Headache
• Fever
• Chills
• Hiccups
• Nausea
• Vomiting
• Malaise (feeling of poor health)

Some symptoms of PID are:

• Vaginal discharge
• Lower abdominal pain
• Menstrual irregularities
• Dyspareunia (pain during intercourse)

Diagnosis

Fitz-Hugh-Curtis syndrome is difficult to diagnose. Multiple laboratory tests are performed, and conditions are observed for diagnosis.⁷

The following are the laboratory diagnosis tests that are performed:

• Test for sexually transmitted infections
• Pregnancy test
• Complete blood count
• Vaginal smears

Some radiological examinations include:

• Transvaginal ultrasonographic scan
• MRI
• CT scan

Differential diagnosis

Fitz-Hugh-Curtis syndrome symptoms may also be responsible for some other conditions, which include:

• Appendicitis
• Cholecystitis
• Ectopic pregnancy
• Liver abscess
• Hepatitis
• Pleurisy (inflammation of the pleura)

Treatment

Fitz-Hugh-Curtis syndrome focuses on the treatment of underlying infections, and initially, it is treated by multiple means.³

Antibiotics

Antibiotic therapy is the mainstream treatment for FHCS patients. Different regimens of tetracyclines, doxycyclines, ofloxacin, metronidazole, ceftriaxone, and multiple other antibiotics are prescribed for the treatment of underlying infections.⁸

NSAIDs and analgesics

In some cases, pain mediators such as analgesics, which include acetaminophen or codeine, are used for the management of pain. NSAIDs, e.g., ibuprofen or naproxen, are also used. 

Laparoscopy 

If antibiotics do not provide relief from symptoms, then a surgical treatment called laparoscopy is performed. During this surgery, the adhesions from the peritoneal cavity are removed.

Complications

• The main complication of Fitz-Hugh-Curtis syndrome is infertility. When it is not treated on time and gets severe, it may cause infertility
• Bowel obstruction may also occur due to the formation of adhesions in the peritoneal cavity

FAQs

Can Fitz-Hugh-Curtis syndrome cause infertility?

If it is not properly treated, it causes infertility because of its association with PID, which creates scar tissue in the fallopian tube. Due to this scar tissue, the fallopian tube gets blocked, preventing conception.

Can Fitz-Hugh-Curtis syndrome cause bowel obstruction?

Yes, bowel obstruction can occur due to adhesion formation in the peritoneal cavity.

Is Fitz-Hugh-Curtis syndrome curable?

Yes, FHCS is curable, usually responds well to antibiotics, and often leads to a full recovery with no long-term complications.

What is Fitz-Hugh-Curtis syndrome in TB?

FHCS, or acute perihepatitis, is considered a rare complication of PID, mostly associated with chlamydial or gonococcal salpingitis. Peritoneal tuberculosis is a rare site of extrapulmonary infection caused by Mycobacterium tuberculosis.

What is Fitz-Hugh-Curtis syndrome in children?

FHCS in children is frequently associated with stomach infections and causes perihepatitis. It is unknown if this is a direct ascending, lymphogenic, or immunological response.³

What is Fitz-Hugh-Curtis syndrome in people assigned male at birth (AMAB)?

It occurs mostly in premenopausal people assigned female at birth (AFAB). However, cases in people with AMAB have also been reported. Diagnosis is made by clinically eliminating other causes of right upper quadrant pain.⁹

Can you get pregnant with Fitz-Hugh-Curtis syndrome?

If it is not treated at the right time or if the infection is severe, it can affect the person's fertility.

What is the fastest way to cure PID?

To fully treat PID, you may need to take one or more antibiotics. Taking antibiotics will help clear the infection in about 2 weeks. 

Does PID cause leg pain?

Sometimes the lower abdominal pain radiates to the leg.

Why do I feel gas in my pelvic area?

Sometimes, gas can become trapped within the pelvic region, leading to distension and discomfort. This can occur due to various factors, such as a blockage or narrowing of the intestines, muscle spasms, or pelvic floor dysfunction.

Does Fitz-Hugh-Curtis syndrome cause elevated liver enzymes?

No, it does not elevate the liver enzymes. Liver enzyme levels are usually normal or sometimes slightly elevated.

Summary

Fitz-Hugh-Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease (PID), characterised by inflammation of the liver capsule and the formation of adhesions, leading to severe pain in the upper right abdomen. It affects sexually active women between the ages of 15 and 30 and is commonly caused by sexually transmitted infections, particularly chlamydia and gonorrhoea.

The syndrome develops when pathogens from the pelvic region ascend through the reproductive tract and reach the liver capsule via the bloodstream, peritoneal cavity, or lymphatic system. This causes perihepatitis and adhesions between the liver and diaphragm, which are known as "violin-string" adhesions. Symptoms include sharp pain in the upper right abdomen, which may radiate to the shoulder, along with fever, nausea, and other signs of PID such as vaginal discharge and menstrual irregularities.

Diagnosis involves laboratory tests for STIs and imaging studies like ultrasound or CT scans. Treatment focuses on antibiotic therapy to address the underlying infection, along with pain management. In severe cases, laparoscopy is needed to remove adhesions, while untreated FHCS can lead to complications such as infertility and, rarely, bowel obstruction.