AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Originally described in 1920, Fitz-Hugh-Curtis (FHC) syndrome (formally known as Fitz-Hugh and Curtis syndrome) consists of right upper quadrant pain resulting from ascending pelvic infection and inflammation of the liver capsule or diaphragm. Although it is typically associated with acute salpingitis, it can exist without signs of acute pelvic inflammatory disease (PID). In that respect, FHC syndrome can mimic other abdominal emergencies and is often a diagnosis of exclusion.

Pathophysiology

FHC is an extrapelvic manifestation of PID. It is associated with right upper quadrant pain that likely results from inflammation of the liver capsule and diaphragm. Previously, Neisseria gonorrhoeae was thought to be the main causative agent. However, recent studies have shown that cases of FHC due to Chlamydia trachomatis infection outnumber those due to N gonorrhoeae infection by almost 5 to 1. The spread of bacteria from the pelvis to the liver capsule likely results from the circulation of abdominal fluid over the right paracolic gutter to the subphrenic space and hepatic surface. However, lymphatic and hematogenous spread have not been excluded, and these probably play a role in the dissemination of the disease.

Frequency

International

FHC syndrome occurs in 15-30% of women with PID.

Sex

• It is a disease that overwhelmingly affects females, although a few cases have been reported in males.

Age

• FHC occurs in reproductive-aged women.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

Fitz-Hugh-Curtis (FHC) syndrome consists of 2 phases, termed acute and chronic.

• Acute phase
• • Acute onset of excruciating sharp pain over the area of the gallbladder
  • Possible referred pain to the right shoulder
  • Pleuritic pain that increases with Valsalva (ie, any maneuver that increases intra-abdominal pressure, eg, cough, sneeze) or movement
  • Occasional nausea, vomiting, hiccups, chills, fever, night sweats, headaches, or general malaise
  • Most often associated with acute salpingitis but symptoms of FHC without signs of PID are possible
• Chronic phase - Characterized by persistent right upper quadrant pain or relief of symptoms altogether

Physical

Without a diagnosis of PID, FHC is most often a diagnosis of exclusion.

• Typically, no pathognomonic signs are present upon physical examination.
• The diagnosis is inferred from symptoms and positive culture findings for gonorrheal or chlamydial organisms.
• Listening at the anterior costal margin may reveal a finding described as a "walking-in-new-snow" type of crunching friction rub.

Causes

FHC is caused by infection with C trachomatis or N gonorrhoeae.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Other Problems to be Considered

Ectopic pregnancy
Pyelitis
Pyelonephritis
Pylephlebitis
Peritonitis
Subphrenic abscess

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• Lab test findings are consistent with those of acute PID.
• • Cervical cultures for gonorrhea and chlamydia
  • Elevated WBC count and erythrocyte sedimentation rate
• Because FHC rarely affects liver parenchyma, LFT results are rarely affected.
• Rule out other disease.
• • Amylase or lipase to help exclude gallbladder disease
  • LFTs to help exclude hepatitis
  • Urinalysis or urine culture to help exclude pyelonephritis or kidney stones
  • Stool guaiac to help exclude perforated ulcer

Imaging Studies

• Ultrasonography
• • Case reports exist that indicate visualizing perihepatic adhesions may be possible, especially when fluid is present in the abdominal cavity.
  • One study found an increase in the width of anterior extrarenal tissue due to inflammation.
  • Ultrasonographic findings help exclude the presence of gallstones.
• CT scan
• • CT scan findings may help delineate a loculated perihepatic peritoneal collection.
  • Findings help exclude the presence of other diseases.
• Chest radiograph
• • The right hemidiaphragm may be elevated.
  • Findings help exclude the presence of pneumonia.
  • Check for free air to help rule out perforation.

Procedures

• Diagnostic laparoscopy
• • This is the criterion standard procedure for diagnosis.
  • Most diagnoses are made with after direct visualization of the liver capsule.
  • During the acute phase, inflammation of the peritoneum and anterior liver capsule is present and exudate that is gray and flaky or granular appears. The exudate has been described as looking like salt sprinkled on a moist surface.
  • During the chronic phase, the classic "violin-string" adhesions of the anterior liver capsule to the anterior abdominal wall or diaphragm are present (see Image 1).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Medical Care

• Antibiotics are the mainstay of therapy for Fitz-Hugh-Curtis (FHC) syndrome.
• Treatment is the same as for PID.
• Patients may be treated in an outpatient setting unless they meet one of following criteria:
• • Positive for human immunodeficiency virus infection
  • Unilateral or bilateral tubo-ovarian abscess
  • Oral intake not possible due to secondary nausea or vomiting
  • Outpatient treatment has failed
  • Pregnant

Surgical Care

• Laparoscopy is the criterion standard for diagnosis.
• Relief of symptoms with lysis of adhesions is of questionable benefit.

Consultations

• Consultation with a gynecologist may be indicated, especially if considering admission.

Activity

• Sexual activity should be restricted until the patient's partner is treated.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Antibiotics and pain control agents are the medications of choice to treat Fitz-Hugh-Curtis (FHC) syndrome. Use the same antibiotics as would be used to treat PID. See Treatment for criteria regarding outpatient treatment regimens versus inpatient treatment regimens. Pain control may be achieved with NSAIDs or acetaminophen with codeine (Tylenol #3).

Drug Category: Outpatient antibiotic regimen #1

Includes antibiotics to treat the common causes of PID. This regimen includes both ceftriaxone and doxycycline.

Drug Name	Doxycycline (Doryx, Vibramycin)
Description	Broad-spectrum antibiotic. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose	100 mg PO bid for 14 d
Pediatric Dose	<100 lb: 2 mg/lb PO divided bid for 14 d >100 lb: Administer as in adults
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Drug Category: Outpatient antibiotic regimen #2

Includes antibiotics used to treat the common causes of PID. Regimen includes both ofloxacin and metronidazole (Flagyl)

Drug Name	Metronidazole (Flagyl)
Description	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Adult Dose	500 mg PO bid for 14 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiramlike reaction may occur with orally ingested ethanol
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Drug Category: Inpatient antibiotic regimen #1

Includes antibiotics used to treat the common causes of PID. This regimen includes both cefotetan and doxycycline.

Drug Name	Doxycycline (Doryx, Vibramycin)
Description	Broad-spectrum antibiotic. Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose	100 mg PO/IV q12h
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Unsafe in pregnancy
Precautions	Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Drug Category: Inpatient antibiotic regimen #2

Includes antibiotics to treat the common causes of PID. This regimen includes both clindamycin and gentamicin.

Drug Name	Gentamicin (Gentacidin, Garamycin)
Description	Good aerobic coverage. Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Not the DOC. Consider using if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Adult Dose	2 mg/kg loading dose IV, then 1.5 mg/kg q8h
Pediatric Dose	6-7.5 mg/kg/d (2-2.5 mg/kg q8h) IV
Contraindications	Documented hypersensitivity; renal insufficiency not on dialysis
Interactions	Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular-blocking agents, thus, prolonged respiratory depression may occur; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)
Pregnancy	D - Unsafe in pregnancy
Precautions	Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who experience pain.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Inpatient Care

• Continue inpatient antibiotics until the patient is able to tolerate oral intake, is afebrile, and has improvement in abdominal pain.
• Switch to an oral regimen to complete the 14-day antibiotic course.

Further Outpatient Care

• Perform a follow-up examination in 48-72 hours to document improvement of symptoms.
• Treat the patient's sexual partner for gonorrhea and chlamydia.

Deterrence/Prevention

• Use condoms.
• Limit the number of sexual partners.

Prognosis

• Prognosis is excellent.
• Most cases are asymptomatic (ie, difficult to diagnose clinically) and are diagnosed only at the time of surgery, when Fitz-Hugh-Curtis syndrome is in the chronic stage.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  "Violin-string" adhesions of chronic Fitz-Hugh-Curtis syndrome.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

• Counselman FL. An unusual presentation of Fitz-Hugh-Curtis syndrome. J Emerg Med. Mar-Apr 1994;12(2):167-70. [Medline].
• Gilbert DN, Moellering RC Jr, Sande MA. The Sanford Guide to Antimicrobial Therapy. 29th ed. Hyde Park, Vt: Antimicrobial Therapy; 1999.
• Lopez-Zeno JA, Keith LG, Berger GS. The Fitz-Hugh-Curtis syndrome revisited. Changing perspectives after half a century. J Reprod Med. Aug 1985;30(8):567-82. [Medline].
• McCormick M, DelCastillo J, Berk RS. An atypical presentation of the Fitz-Hugh-Curtis syndrome. J Emerg Med. Jan-Feb 1990;8(1):55-8. [Medline].
• Micromedex. Drugdex Drug Evaluation. Englewood, Colo: Micromedex; 1999.
• Perlman PE, Mills RL. Fitz-Hugh-Curtis syndrome. Am Fam Physician. Oct 1987;36(4):162-4. [Medline].
• Romo LV, Clarke PD. Fitz-Hugh-Curtis Syndrome: pelvic inflammatory disease with an unusual CT presentation. J Comput Assist Tomogr. Sep-Oct 1992;16(5):832-3. [Medline].
• Schoenfeld A, Fisch B, Cohen M. Ultrasound findings in perihepatitis associated with pelvic inflammatory disease. J Clin Ultrasound. Jun 1992;20(5):339-42. [Medline].
• Schrander-vd Meer AM, de Nooyer CA, Ferwerda J. The Fitz-Hugh-Curtis syndrome, an unusual presentation. Neth J Med. Dec 1995;47(6):278-80. [Medline].
• van Dongen PW. Diagnosis of Fitz-Hugh-Curtis syndrome by ultrasound. Eur J Obstet Gynecol Reprod Biol. Jul 1993;50(2):159-62. [Medline].

Article Last Updated: Aug 28, 2006