A Forgotten Cause of Acute Abdominal Pain

Abstract

Fitz-Hugh-Curtis syndrome (FHCS) is a rare complication of pelvic inflammatory disease (PID) that involves liver capsule inflammation, leading to creation of adhesions. It occurs most commonly in women of childbearing age. However, it has been reported in men. An 18-y.o. G1P1 female presented to the ER with one week history of severe intermittent RUQ pain, radiating to her right shoulder; each pain episode lasting about 30 minutes. On day of admission, her pain lasted for 5 hours, with no other GI or GU symptoms. She was vitally stable and her exam was unremarkable except for mild RUQ tenderness. Urine pregnancy test, US, and CT abdomen with IV contrast were negative. She was put on supportive therapy with pain medications but continued to have severe pain and repeat CT abdomen was negative. On detailed history, she reported unprotected coitus. PCR for Gonorrhea and Chlamydia later came back positive. Gynecological evaluation revealed normal uterus, cervix without motion tenderness, and non-tender adnexa. She was started on antibiotics but continued to have excruciating pain. Diagnostic laparoscopy was therefore performed showing turbid pelvic fluid, bilateral injected fallopian tubes both adherent to the sigmoid colon, appendix adherent to the right fallopian tube, right liver lobe surface with hemorrhagic exudates mirroring the overlying peritoneal surface, normal ovaries, uterus and gallbladder. Adhesions were lysed. The findings were consistent with acute PID with FHCS. Intra-abdominal cultures remained negative. She improved clinically and was discharged to complete a course of oral antibiotics. FHCS is a type of perihepatitis that causes liver capsule inflammation without affecting hepatic parenchyma. FHCS consists of RUQ pain following transabdominal spread of infection from PID. During the chronic phase, adhesions form between the anterior liver capsule and the anterior abdominal wall or diaphragm, classically described as ‘violin strings'. FHCS provides a diagnostic challenge as it can mimic many other diseases, most often acute cholecystitis. Non-invasive diagnostic modalities are usually non-revealing, and diagnostic laparoscopy for direct visualization is often required. Therefore, a high index of clinical suspicion is needed to avoid delay in treatment initiation and increased morbidity. Clinicians should be made aware that FHCS cannot be excluded when patients present with RUQ abdominal pain without significant signs of biliary tract disease.