Article Type : Case Report
Authors : Gomathi P
Keywords : Fitz-Hugh–Curtis syndrome; Pelvic infections; Liver capsular
Fitz-Hugh–Curtis
syndrome (FHCS) is defined as peri-hepatic inflammation due to disseminated
PID; with Chlamydia trachomatis and Neisseria gonorrhoea being the main
aetiologic agents. The main mechanism of this pathology is attributed to
hemato-lymphatic and peritoneal spread of pelvic infections to the liver and
hyper-immune response to Chlamydia trachomatis infection with both processes
leading to peri-hepatic and liver capsular inflammation. Typically, patients
with FHCS are women of childbearing age who visit a hospital with complaints of
acute pain or chronic tenderness in the right upper abdomen. A thorough history
and a high index of suspicion are necessary to reach an appropriate diagnosis.
Right upper quadrant abdominal pain is a symptom of myriad pathologies
including, but not exclusive to, cholecystitis, pleurisy, right pyelonephritis,
subphrenic abscess, or herpes zoster infection, making an assessment for FHCS
particularly difficult.
The
incidence of ectopic presenting with Fitz-hugh-curtis syndrome is 14-34%. The
case presented here is to reiterate the need for early diagnosis and treatment
of PID to prevent major complications like ectopic gestation.
A
21 Year old Primi, married 1yr, diagnosed to have right ectopic gestation
medical management done with injection methotrexate as per protocol, on serial
follow up beta hcg was reducing, after 3 weeks patient came with history of
acute pain abdomen, ultrasound revealed ruptured ectopic, beta hcg was 1411, proceeded
with laparoscopy which revealed right cornual ectopic around 2cms with omental
adhesions over it and proceeded with total salpingectomy with cornual resection
after taking encircling sutures at cornual end. Left tube was found adherent to
left round ligament and omentum, the same released and anatomy restored.
Further evaluation revealed strings of adhesions seen between anterior surface
of liver and anterior abdominal wall very typical of Fitz -hugh -curtis
syndrome as a consequence of chronic Pelvic inflammatory disease (PID) seen in
this patient. Post-operative period was uneventful. Patient and her partner was
treated for chronic PID as per CDC guidelines.
Fitz-Hugh-Curtis syndrome is a condition in which, as a result of pelvic inflammatory disease, the liver capsule becomes involved with inflammatory exudate that later leaves violin string adhesions.
Although
in the past Neisseria gonorrhea was thought to be the only etiological agent,
recent data indicate that Chlamydia trachomatis may play an important role in
perihepatitis. Perihepatic adhesions may be an after effect of the acute
hepatic episode, and because the cause of ectopic pregnancy is thought to be
salphingitis, women with an ectopic pregnancy may have a higher prevalence of
coexisting perihepatic adhesion [1].
Direct
observation of the liver and pelvis through laparoscope is the most definitive
method of diagnosing salpingitis and perihepatitis. Standard treatment regimens
recommended for salpingitis are adequate also for treatment of perihepatitis.
Pelvic inflammatory
disease can lead to potentially serious complications like ectopic pregnancy,
subferility, chronic pelvic pain and psychological morbidity. A thorough
history and a high index of suspicion are necessary to reach an appropriate
diagnosis. It should treated proactively including partner tracing to avoid
such dreadful complications.