Perihepatitis (Fitz-Hugh-Curtis Syndrome)

Findings

📄 Report Sample Line- Perihepatitis
Showing thickening (7.4 mm) between the liver and the diaphragm. The hepatic capsule is shown as three layers on the right subcostal scan. The inner hyperechoic middle hypoechoic and outer hyperechoic layers of the hepatic capsule. Features are compatible with inflammation of the liver surface, a small amount of ascites, and the inflammation of the diaphragm or abdominal wall, respectively.

Conclusion

📋 Perihepatitis.

Recommendation:

Fitz-Hugh-Curtis syndrome (FHCS), or perihepatitis, is a chronic manifestation of pelvic inflammatory disease (PID). It is described as an inflammation of the liver capsule, without the involvement of the liver parenchyma, with adhesion formation accompanied by right upper quadrant pain. A final diagnosis can be made through laparoscopy or laparotomy via direct visualization of violin string-like adhesions or through hepatic capsular biopsy and culture.

The syndrome was first illustrated by Stajano in 1920 in a non-English publication. In 1930 Curtis described adhesions between the anterior surface of the liver and the abdominal wall found during laparotomies in patients with atypical gallbladder attacks. He noted that while no other upper abdominal pathology was found, residual gonococcal tubal changes were frequently observed in the subjects.

In 1934, Fitz-Hugh, Jr. described similar cases which had presented with right upper quadrant abdominal pain. Laparotomy showed unusual, localized peritonitis involving the anterior surface and edge of the liver and adjacent peritoneal surface of the diaphragm. After drainage, tube insertion smears from drained fluid showed gram-negative, intracellular, biscuit-shaped diplococci. It is now known, however, that the syndrome is not exclusive to gonococcal infection and has been reported in both sexes.
Symptoms

• Abdominal pain localized in the right upper quadrant (RUQ).

Ultrasound Findings

• The ultrasonographic findings of FHCS may be normal, but a report indicated that a thickened hepatic capsule and ascites could be observed on ultrasonography.


• Given the pathophysiology of FHCS, ultrasonographic images that suggest perihepatitis is an important finding in the recognition of FHCS.


• Unfortunately, ultrasonographic images of patients with FHCS that show inflammation and ascites between the liver and the diaphragm or abdominal wall are rarely observed.

(A) Right subcostal POCUS scan showing abnormal thickening (0.74 cm) between the liver and the diaphragm.

(B) According to the scan angle and respiration, the hepatic capsule is shown as three layers on the right subcostal scan. The inner hyperechoic (blue arrow), middle hypoechoic (white arrow), and outer hyperechoic layers (red arrow) of the hepatic capsule are thought to indicate the inflammation of the liver surface, a small amount of ascites, and the inflammation of the diaphragm or abdominal wall, respectively.

(C) In the arterial phase of the CECT scan, hepatic capsular enhancement (red arrowhead) and a small amount of localized ascites (white arrowhead) were observed on the surface of segment IV of the liver. POCUS, point-of-care ultrasonography; CECT, contrast-enhanced computed tomography.
Radiological Findings

• CT scan will show increased perihepatic enhancement in the arterial phase, with a majority of patients also showing pelvic fat infiltration. Other findings associated with PID can be found: pyosalpinx, tubo-ovarian abscess, and fluid collection in the pelvic cavity.
• Transvaginal ultrasonographic scanning is a favorable option for cases in which a clinical picture of PID may be unclear. Findings can include hydrosalpinx, pyosalpinx endometritis, tubo-ovarian abscess, oophoritis, and ectopic pregnancy.
• MRI can show tubo-ovarian abscess, edematous tubes, or free pelvic fluid collections

Contrast-enhanced CT
Department of General Medicine, Chiba University Hospital, Chiba, Japan Correspondence to Dr Kiyoshi Shikino.
Description
A 29-year-old woman presented with 2 days of right upper abdominal pain. The pain worsened with deep breathing and body movements, which radiated to the right shoulder. Physical examination revealed tenderness on palpation of the right upper abdomen and tenderness to percussion of the lower ribs. Endocervical culture revealed Chlamydia trachomatis. Abdominal contrast-enhanced CT showed conspicuous increased perihepatic enhancement on the right lobe of the liver.

Contrast-enhanced CT (axial) showed conspicuous increased perihepatic enhancement on the right lobe of the liver (arrows).

Contrast-enhanced CT (coronal) showed conspicuous increased perihepatic enhancement on the right lobe of the liver (arrows). Fitz-Hugh-Curtis syndrome is considered a rare complication of pelvic inflammatory disease, mostly associated with C. trachomatis. The right upper abdominal pain appears as the main symptom and becomes more severe in response to deep breathing and body movements. Occasionally, the pain may radiate to the right shoulder. The increased enhancement along the hepatic surface on CT has been described as a finding that can suggest the diagnosis of Fitz-Hugh-Curtis syndrome.