Description

A previously healthy woman in her mid-20s was admitted to the emergency department with a 2-day history of right-upper-quadrant abdominal pain, exacerbated with deep inhalation and movement. She also recalled distressing pain during intercourse 2 days earlier. Additionally, she reported viscous vaginal bleeding for the past 10 days. Physical examination revealed that she was afebrile and exhibited tenderness on palpation of the right upper abdomen with a positive Murphy’s sign. Laboratory studies showed a white cell count of 12.6x10ˆ9/L (reference range 3.5x10ˆ9/L-9.1x10ˆ9/L); results in the normal range of aspartate aminotransferase, alanine aminotransferase and bilirubin levels; and a negative pregnancy test. A dynamic abdominal CT scan revealed pronounced perihepatic surface enhancement spanning the right and left lobes in the arterial phase, which disappeared in subsequent phases (figure 1). Despite the absence of evidence of pelvic inflammatory disease on the pelvic CT scan, subsequent gynaecological evaluation revealed manifestations consistent with pelvic inflammatory disease, including dark, mucoid vaginal discharge and cervical motion tenderness. PCR for vaginal discharge was positive for Chlamydia trachomatis and negative for Neisseria gonorrhoeae. Based on these clinical findings, a diagnosis of Fitz-Hugh-Curtis syndrome was established. Complete resolution of symptoms was achieved after intravenous ceftriaxone (1 g once daily for 1 day) administration, followed by oral levofloxacin (500 mg once daily for 7 days).

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Dynamic abdominal CT scan on admission illustrating a pronounced enhancement of the perihepatic surface spanning the right and left lobes (arrows) in the arterial phase (A) but absent in the portal venous (B) and delayed phases (C).

Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease, and while laparoscopic examination and identification of causative organisms in the hepatic capsule are definitive, the clinical diagnostic realm increasingly relies on the capabilities of contrast-enhanced CT scans. Several studies have underscored the importance of dynamic CT scans in discerning Fitz-Hugh-Curtis syndrome, especially in the arterial phase.1 2 In a retrospective review of 25 Fitz-Hugh-Curtis syndrome cases, the combined use of arterial and portal venous phases proved markedly more accurate than the latter alone.3 Another study, zeroing in on patients with abdominal pain in emergency settings, validated the diagnostic supremacy of the arterial phase for Fitz-Hugh-Curtis syndrome.4

However, this brings forth an essential caveat: the arterial phase’s tell-tale sign of increased perihepatic enhancement, suggesting perihepatitis, is not the exclusive domain of Fitz-Hugh-Curtis syndrome. Conditions such as peritonitis, acute pancreatitis, appendicitis and certain hepatobiliary conditions, such as cholecystitis and cholelithiasis, can present with similar CT findings.5 6 Furthermore, in situations where only a single-phase contrast-enhanced CT is conducted, which is common in emergency departments, a risk of missing vital diagnostic indicators could occur such as perihepatic enhancement, exemplified by the current case. Given the patient’s symptomatology and physical findings,7 Fitz-Hugh-Curtis syndrome was suspected before CT evaluation. Consequently, a comprehensive evaluation, encompassing a detailed patient history and meticulous physical examination, remains crucial. Clinicians, therefore, must be aware of Fitz-Hugh-Curtis syndrome in sexually active women presenting with right-upper-quadrant pain and be cognisant of the inherent limitations of contrast-enhanced CT scans.