2324 Right Upper Quadrant Pain in a Young Woman Isn't Always Biliary in Origin: A Case of Fitz-Hugh–Curtis Syndrome (FHCS)

Abstract

INTRODUCTION: Fitz-Hugh–Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease (PID) causing inflammation of the liver capsule and peri-hepatic peritoneal surfaces. It usually is caused by Neisseria gonorrhoeae or Chlamydia trachomatis ascending from genital tract infections. Here we present a case of right upper quadrant (RUQ) abdominal pain initially thought to be biliary in origin, with the etiology ultimately thought to be FHCS. CASE DESCRIPTION/METHODS: A 24-year-old woman with no significant past medical history presented to the emergency department with RUQ abdominal pain for one week. The pain was described as sharp, constant, “pinching and pulling” in quality, worsened by coughing and deep breathing, and associated with nausea and vomiting. While she reported being sexually active, there were no genital or urinary symptoms or any history of sexually transmitted infections. Physical examination was notable for RUQ tenderness with positive Murphy’s sign. Pelvic exam was negative for cervical motion tenderness (CMT), adnexal or uterine tenderness, cervical or vaginal discharge. Labs were significant only for leukocytosis of 13.5 K/uL and an elevated total bilirubin to 1.7 mg/dL, both of which resolved within 24 hours. Abdominal ultrasound and magnetic resonance cholangiopancreatography showed no evidence of cholecystitis or gallstones. Given persistent symptoms despite improving blood work and unremarkable imaging, the leading concern was biliary colic or sludge. Diagnostic laparoscopy was performed, showing an injected peri-hepatic diaphragmatic peritoneum and focal adhesions between the liver capsule and anterior abdominal wall, suggesting FHCS. Of note, all gynecologic organs were inspected and appeared normal. Gallbladder was removed during the procedure as a precaution, and pain resolved shortly after surgery. Nucleic acid amplification test for Chlamydia trachomatis ultimately was positive, confirming the diagnosis of FHCS. DISCUSSION: FHCS usually presents with RUQ abdominal pain that mimics hepatobiliary etiologies, and usually is associated with symptoms of PID including pelvic/lower abdominal pain, vaginal discharge or CMT. This case of FHCS is atypical in that the patient presented only with RUQ pain in the absence of PID symptoms, which may be due to bacteria bypassing pelvic structures on the way to the liver capsule. FHCS should be considered in the differential diagnosis of RUQ abdominal pain in young women of reproductive age.