Fitz Hugh Curtis Syndrome (FCHS), otherwise known as peri-hepatitis, is a known complication of Pelvic Inflammatory Disease (PID). FCHS is caused by the infection of the tissues surrounding the liver.1 It is a condition which predominantly affects people assigned female at birth (AFAB) and occurs as a consequence of long-standing sexually transmitted infections. Conditions that may lead to FHCS include Chlamydia and Gonorrhoea. This article will explore the symptoms, diagnostic criteria and management options, providing all relevant information.
Pathophysiology of Fitz-Hugh-Curtis Syndrome
As mentioned previously, the syndrome is primarily associated with pelvic inflammatory disease, an infection of the female reproductive organs. The exact mechanism behind the spread of infection to the liver is not fully understood. However, some believe that bacteria can gain access to the abdomen through the bloodstream or through the fallopian tubes of the female reproductive system.1 Once the bacteria arrive in the abdomen, they can travel to the liver and associated structures.1 Eventually, the collection of bacteria will lead to inflammation and the typical symptoms of FHCS.
Causes of Fitz-Hugh-Curtis Syndrome
Some of the most common causes include:
Signs and Symptoms of Fitz-Hugh-Curtis Syndrome
The most common symptom is pain in the upper right side of the abdomen.2 If the inflammation affects the diaphragm, then this can lead to nerve irritation which can result in shoulder pain on the right-hand side.2 Vaginal discharge is often also present.2
As the syndrome is a complication of an underlying infection, general infection symptoms may be present. These include:2
- Sweating during the night
If the complication arises due to a pre-existing sexually transmitted infection, then the individual affected may already have symptoms linked to chlamydia and gonorrhoea infections. These include lower abdominal pain, yellow/green vaginal discharge or foul-smelling discharge.
How is Fitz Hugh Curtis Syndrome Diagnosed?
Before it can be diagnosed, other causes of right upper quadrant pain must be ruled out. This includes:2
- Cholecystitis (bile duct inflammation)
- Duodenal ulcers
- Liver Abscess
One key test used is called Diagnostic Laparoscopy.2 This involves making small incisions in the abdomen under general anaesthetic and using a camera to visualise the contents of the abdomen. The camera will be directed towards the liver and will be used to check for adhesions and signs of infection in the liver capsule2.
Imaging studies can also play a vital role. Computed Tomography (CT) scans can reveal the presence of inflammation around the liver, confirming the presence of the syndrome.3
Treatment of Fitz-Hugh-Curtis Syndrome
Any treatment plan needs to address the underlying pelvic inflammation and the current symptoms. Therefore, treatment plans often include antibiotics to control any underlying infections.4 The particular antibiotic given will rely on the results seen after swabs and other investigations.4 Examples of antibiotics given include doxycycline.2
After the treatment course is completed and symptoms have subsided, it is important to arrange follow-up testing and consultations to ensure that there are no underlying infections remaining.
As Fitz-Hugh-Curtis syndrome is linked to Pelvic Inflammatory Disease, prevention often involves reducing the chances of developing PID. In order to prevent Pelvic Inflammatory Disease, any existing sexually transmitted infections should be treated promptly.
It is recommended that individuals who have had a new sexual partner should test themselves for STIs. The UKHSA states that everyone should have an annual STI screen, including for HIV if having unprotected intercourse with new or casual partners. It also states that sexually active women and other people with a womb or ovaries aged under 25 should be tested for chlamydia annually or whenever they change sexual partners. It is not advised to wait for symptoms to show before getting an STI test. It is possible for an individual to be asymptomatic and show no signs of having an STI.5 As a result, it becomes even more important to test regularly to prevent infections from remaining undetected and developing into Pelvic Inflammatory Disease.
How does STI Testing work?
In the UK, many areas now offer self-sampling kits so that patients can test for infections in the comfort of their own homes. These are usually for those who do not have any symptoms and are testing routinely. These kits are used to test for common sexual infections such as chlamydia and gonorrhoea. These infections are often the most common culprit behind FHCS so these kits are very helpful.
Self-sampling kits often include a blood sample pack to test for HIV, swabs to be used on the genitals and throat and urine sample pots. The urine sample pots and swabs are the tests that are used to detect chlamydia and gonorrhoea. The kit must be sent back to the lab for analysis and there will usually be an envelope provided to post them back. Test results will be provided by text message within a few days. It is important to note that there is often a 2-week window between coming into contact with a chlamydial infection and getting a positive STI result. It is therefore important to make sure that samples are sent within 2 weeks after exposure.
Signs that individuals may have an STI
It is very important to note that the majority of cases of chlamydia are asymptomatic.5 However, you should consider chlamydia if you are sexually active and have the following symptoms:
- Abnormal vaginal discharge (particularly yellow or green discharge)
- Pelvic pain
- Abnormal vaginal bleeding - either in between periods or after intercourse
- Painful sex
- Painful urination
The complications of chlamydia and FHCS in particular do not usually affect men. However, it is important to note when a sexual partner may have contracted an STI. In the case of men, chlamydia should be suspected when there are:
- Discharge or discomfort when urinating
- Painful urination
- Swollen and painful testicles
- Joint pain along with vision problems and pain urinating - this is known as reactive arthritis
In terms of gonorrhoea, female infections can present with:
- Pelvic pain
- Discharge with yellow or green pus but no smell
- Pain when urinating
Male infections can present with:
- Painful, swollen testicles
- Painful urination
- Yellow or green pus in discharge
Treating and Preventing Common STIs
Preventing STIs often requires the use of barrier protection such as condoms whenever an individual engages in any form of sexual intercourse.
As mentioned previously, chlamydia and gonorrhoea are both bacterial infections and therefore, they are treated with antibiotics. In the UK, chlamydia is treated with a week-long course of doxycycline, which is taken every day for a week. Amoxicillin is also used as an alternative option for treatment. In terms of gonorrhoea, an injection of an antibiotic called ceftriaxone is often used.
Does it affect men/individuals with a male reproductive system?
It is mostly present in women and individuals with a female reproductive system and it is theorised that the bacteria use the fallopian tubes to gain access to the liver and cause inflammation there. However, there have been some studies and cases where a man appeared to have developed Fitz Hugh Curtis Syndrome6. According to studies, this is rare and occurs infrequently. It is theorised that the bacteria are spread in a man through the bloodstream7.
What are the complications of Fitz Hugh Curtis Syndrome?
The syndrome could lead to the creation of adhesions, which are a type of internal scar tissue that connects tissues together.8 This could lead to organs and tissues being moved out of place and could cause symptoms such as pain.
How can Fitz Hugh Curtis Syndrome be prevented?
As mentioned previously in the article, the syndrome can be prevented by treating any sexually transmitted infections swiftly. It is also important to also try to prevent an infection in the first place. This can be done by testing for STIs regularly, using barrier protection and visiting a doctor when any symptoms occur.
Who is at higher risk from Fitz Hugh Curtis Syndrome?
The following groups should be considered for hospitalisation if diagnosed, due to higher risk:4
- Immunodeficient individuals
Most other patients do not necessarily need to be admitted but there are other factors that can influence this.4 For example, if the patient is known to be unreliable when it comes to attending follow-up appointments. If an individual is due to undergo an operation for a different condition, it may be necessary to admit them as well.4 Additionally, if the patient is unable to tolerate oral antibiotics then they may need to be admitted so that the medication can be given intravenously.4
To conclude, Fitz-Hugh-Curtis Syndrome is a rare complication of long-standing untreated sexual infections and pelvic inflammatory disease. It often involves liver inflammation and therefore produces symptoms linked to this. Examples of common signs include right-sided abdominal pain and tenderness. It usually affects individuals AFAB and is diagnosed by ruling out other causes using imaging and lab-based tests. It is treated with pain relief medication and a course of antibiotics. It is important to regularly test for and treat sexually transmitted infections to reduce the risk of Fitz-Hugh-Curtis Syndrome.
- Basit H, Pop A, Malik A, Sharma S. Fitz-hugh-curtis syndrome. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Aug 17]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK499950/
- Theofanakis ChP, Kyriakidis AV. Fitz-Hugh–Curtis syndrome. Gynecol Surg [Internet]. 2011 May [cited 2023 Aug 16];8(2):129–34. Available from: https://link.springer.com/10.1007/s10397-010-0642-8
- Nishie A, Yoshimitsu K, Irie H, Yoshitake T, Aibe H, Tajima T, et al. Fitz-hugh-curtis syndrome. Radiologic manifestation. J Comput Assist Tomogr. 2003;27(5):786–91. Available from: https://pubmed.ncbi.nlm.nih.gov/14501371/
- Peter NG, Clark LR, Jaeger JR. Fitz-Hugh-Curtis syndrome: a diagnosis to consider in women with right upper quadrant pain. Cleveland Clinic Journal of Medicine [Internet]. 2004 Mar 1 [cited 2023 Aug 17];71(3):233–9. Available from: http://www.ccjm.org/cgi/doi/10.3949/ccjm.71.3.233
- Geisler WM. Duration of untreated, uncomplicated Chlamydia trachomatis genital infection and factors associated with chlamydia resolution: a review of human studies. J Infect Dis. 2010 Jun 15;201 Suppl 2:S104-113. Available from: Duration of untreated, uncomplicated Chlamydia trachomatis genital infection and factors associated with chlamydia resolution: a review of human studies - PubMed (nih.gov)
- Saurabh S, Unger E, Pavlides C. Fitz -Hugh-Curtis syndrome in a male patient. Journal of Surgical Case Reports [Internet]. 2012 Mar 1 [cited 2023 Aug 17];2012(3):12–12. Available from: https://academic.oup.com/jscr/article-lookup/doi/10.1093/jscr/2012.3.12
- Baek HC, Bae YS, Lee KJ, Kim DH, Bae SH, Kim DW, et al. A case of fitz-hugh-curtis syndrome in a male. Korean J Gastroenterol [Internet]. 2010 Feb 21 [cited 2023 Aug 17];55(3):203–7. Available from: https://synapse.koreamed.org/articles/1006645
- Coco D, Leanza S. Fitz-hugh-curtis syndrome. Pan Afr Med J [Internet]. 2022 Nov 17 [cited 2023 Aug 17];43:142. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9922068/