Fitz-Hugh–Curtis syndrome

Overview

Fitz-Hugh–Curtis Syndrome (FHCS) is a rare complication of pelvic inflammatory disease (PID), characterized by inflammation of the liver capsule (perihepatitis) without involvement of the liver parenchyma. It primarily affects women of reproductive age and is often associated with sexually transmitted infections (STIs), particularly Chlamydia trachomatis and Neisseria gonorrhoeae. FHCS presents with sharp, right upper quadrant abdominal pain that may mimic other hepatobiliary conditions, making accurate diagnosis critical.

Causes

Fitz-Hugh–Curtis Syndrome is typically caused by the spread of pelvic infections to the liver capsule. The most common causative agents include:

• Chlamydia trachomatis

• Neisseria gonorrhoeae

• Other anaerobic or facultative bacteria associated with pelvic infections

The bacteria ascend from the lower genital tract to the upper reproductive organs and may spread transperitoneally to involve the perihepatic area, leading to inflammation and formation of "violin-string" adhesions between the liver capsule and abdominal wall or diaphragm.

Symptoms

Symptoms of Fitz-Hugh–Curtis Syndrome can overlap with those of PID and other abdominal or hepatobiliary conditions. Common symptoms include:

• Sharp right upper quadrant abdominal pain: Often referred to the right shoulder or worsens with movement or coughing.

• Lower abdominal or pelvic pain: Typical of concurrent PID.

• Fever and chills

• Nausea or vomiting

• Abnormal vaginal discharge

• Dyspareunia (pain during intercourse)

• Menstrual irregularities

Diagnosis

Diagnosing FHCS can be challenging due to its overlap with other abdominal disorders. Key diagnostic steps include:

• Medical history and physical examination: Including evaluation of pelvic pain and STI risk factors.

• Laboratory tests:

  • STI testing (for Chlamydia and Gonorrhea)

  • Elevated inflammatory markers (e.g., ESR, CRP, WBC count)

• Imaging studies:

  • Ultrasound or CT scan: May show inflammation but often nonspecific

  • MRI: Can help detect perihepatic inflammation or adhesions

• Laparoscopy: The gold standard for diagnosis, revealing characteristic “violin-string” adhesions between the liver and peritoneum.

Treatment

Treatment of Fitz-Hugh–Curtis Syndrome focuses on eliminating the underlying infection and managing symptoms. Standard approaches include:

• Antibiotic therapy:

  • Empirical treatment covering Chlamydia and Gonorrhea

  • Common regimen: Ceftriaxone + doxycycline ± metronidazole

• Pain management: NSAIDs or acetaminophen for abdominal pain and inflammation.

• Partner notification and treatment: To prevent reinfection and control STI spread.

• Surgical intervention: Rarely required, but may be considered for adhesiolysis in severe cases or for diagnostic confirmation via laparoscopy.

Prognosis

With prompt and appropriate antibiotic treatment, the prognosis for Fitz-Hugh–Curtis Syndrome is excellent. Most patients recover fully without long-term complications. However, delayed treatment can lead to persistent pelvic pain, chronic adhesions, or infertility. Early diagnosis, proper management of PID, and STI prevention strategies are essential for reducing the risk of developing FHCS and its complications.