Fitz-Hugh-Curtis syndrome

Background

"Violin string sign", adhesions between the liver and abdominal wall.

• A complication of Pelvic Inflammatory Disease, involving acute gonococcal or chlamydia trachomatis peritonitis of the right upper quadrant in women
• Pain is caused by liver capsule inflammation leading to the creation of adhesions

Clinical Features

• Sudden onset of severe right upper quadrant abdominal pain
• Distal pleuritic component +/- radiation to the shoulder
• May not have symptoms of PID

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Evaluation

CT abdomen (A–D = portal venous phase): A. Homogeneously thickened strip of enhancement (black arrow); B. Lesion in the right paracolic gutter area without exact anomaly density; C. Pelvic fat spaces with increased density, inhomogeneous enhancement, and visible rectal effusion (cross); D. Bilateral ovarian abscess (white arrow) and surrounding uterus effusion.

• Aminotransferases usually normal or mildly elevated
  • Generally not markedly elevated
• If CT obtained, may show inflammatory changes in pelvic and perihepatic regions
• Ultimately a diagnosis of exclusion with supporting evidence of gonorrhea or chlamydia

Management

• Fully treat pelvic inflammatory disease

Disposition

• Admission criteria same for PID
  • Pregnancy
  • Toxic, systemic symptoms
  • Poor compliance
  • Failure of outpatient therapy
  • Tubo-ovarian abscess

See Also

• PID