Fitz-Hugh-Curtis syndrome: Description, Causes and Risk Factors:
Fitz-Hugh-Curtis syndrome is a rare disorder that occurs almost exclusively in women. It is characterized by inflammation of the membrane lining the stomach (peritoneum) and the tissues surrounding the liver (perihepatitis). The muscle that separates the stomach and the chest (diaphragm), which plays an essential role in breathing, may also be affected.
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease (PID), a general term for infection of the upper genital tract in women. Infection is most often caused by Neisseria gonorrhoeae (N. gonorrhoeae) and Chlamydia trachomatis (C. trachomatis).For many years, other organisms have been cited in the literature to beassociated with PID/perihepatitis. These microorganisms include aerobic/anaerobic organisms,M. hominis (Mycoplasma hominis) and U. urealyticum (Ureaplasma urealyticum).
The spread of the infection from the pelvis may be due to circulation of peritoneal fluid along the paracolic gutter. A gliding effect of liver during respiration is thought to predispose and contribute to the right sided involvement. Reports of cases in men have raised the possibility of hematogenous or lymphatic spread. Fitz-Hugh-Curtis syndrome is a cell mediated immune response probably resulting to chlamydia heat shock protein 60 (HSP60). The geometric titer of Chlamydia antibody is significantly higher in patients with Fitz-Hugh-Curtis syndrome.
The incidence ranges from 4% to 14% in women with PID, but is as high as 27% in adolescents with PID, whose less mature anatomy makes them more susceptible to infection.
Common symptoms include severe pain in the upper right area (quadrant) of the abdomen, fever, chills, headaches
, and a general feeling of poor health (malaise).
There is both an acute and chronic phase
In the acute phase the following features are often found:
Acute onset of severe, sharp pain in the right upper quadrant and especially over the area of the gallbladder.
- Pain may be referred to the right shoulder.
- Pain is pleuritic in nature and anything that increases intra-abdominal pressure, such as a cough, sneeze or movement, is associated with a sharp aggravation of the pain.
- There may possibly be nausea, vomiting, hiccups, chills, fever, night sweats, headaches, and general malaise.
- There are often features of acute salpingitis but this is not invariable.
The chronic phase may show persistent, dull pain in the right upper quadrant or the pain may subside.
The diagnosis of the Fitz-Hugh-Curtis syndrome depends on a high clinical index of suspicion. In a sexually active patient with symptomsconsistent with PID and right upper abdominal pain, the diagnosis of perihepatitismust be considered. This syndrome is a diagnosisof exclusion; therefore, the more common causes ofupper abdominal pain, i.e., hepatitis, cholecystitis,peptic ulcer disease, and pneumonia, must be ruledout. The onset of right-upper-quadrant pain in patients with the Fitz-Hugh-Curtis syndrome is variable.
There are several tests for C. trachomatis and N. gonorrhoeae. Cultures are still widely used, but genetic amplification tests such as the ligase chain reaction (LCR) and nucleic acid amplification test are highly sensitive and specific, making them promising for diagnosing both N gonorrhoeae and C trachomatis. They can be performed on vaginal, urine, and cervical samples.Their main limitation is their cost. Serologic tests specific for C trachomatis can also be helpful.
Radiographic studies are most useful to rule out other possible causes. Chest and abdominal radiographs may exclude pneumonia or free air under the diaphragm.
Ultrasonography is the study of choice for evaluating the gallbladder and liver, and can exclude cholecystitis, cholelithiasis, and other common causes of right upper quadrant pain. It can also help evaluate the ovaries for abscesses or other findings consistent with PID. In addition, typical ultrasonographic abnormalities in the perihepatic area have been detected in patients with Fitz-Hugh-Curtis syndrome.
Laparoscopy is often required for final diagnosis. Abnormality of the fallopian tubes may be seen, with possible adhesions. During the acute phase, inflammation of the peritoneum and anterior liver capsule is seen and there may be an exudate that is grey and flaky or granular in appearance. The exudate has been described as like salt sprinkled on a moist surface.In the chronic phase, the classical "violin-string" adhesions of the anterior liver capsule to the anterior abdominal wall or diaphragm may be seen.
The management of Fitz-Hugh-Curtis syndrome is similar to that of PID. Most patients can be treated as outpatients, although hospitalization should be strongly considered if the patient is:
Adolescent (a group whose anatomy and high rate of noncompliance put them at particularly high risk for reproductive complications).
- A potential candidate for surgery.
- Having particularly severe symptoms
- Unresponsive to oral therapy or unable to tolerate oral medication.
Antibiotics should be directed at the most likely pathogens, in particular N. gonorrhoeae, C. trachomatis, facultative gram-negative rods, and anaerobes, since isolation of all offending agents is unlikely.
If pain persists despite adequate treatment, a prompt laparoscopic examination should be performed to determine whether there are adhesions in the perihepatic area or elsewhere. Laparoscopy provides less invasive therapy than laparotomy when lysis of adhesions is necessary for symptom relief.
NOTE: The above information is educational purpose. The information provided herein should not be used during any medical emergency or for the diagnosis or treatment of any medical condition.
DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.