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A rare cause of right-sided abdominal pain in a young woman

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An 18-year-old woman gravida 0, para 0, was admitted with a 3-week history of vague right-sided abdominal pain. She denied any gastrointestinal or urinary symptoms or vaginal discharge. Her last menstrual period was one week prior to admission and was normal. She was sexually active. Her medical history was unremarkable. On examination, she was apyrexic with tenderness along the right side of the abdomen extending from the costal margin to the right iliac fossa, with no guarding or rebound tenderness. Bowel sounds were normal. Pelvic examination revealed slight tenderness on the right side with no masses. White cell count was 5.5 × 109/l, erythrocyte sedimentation rate was not elevated. Pregnancy test and MSSU were negative. Chest and abdominal X-ray was normal. Ultrasound scan showed a small amount of fluid in the pelvis with normal ovaries. She was managed conservatively, but her abdominal pain and tenderness persisted.

Questions

1
What other investigation would you consider?
2
What is the probable diagnosis?

Answers

QUESTION 1

Diagnostic laparoscopy is indicated here in view of atypical pain and non-characteristic signs with non-diagnostic ultrasound scan findings. It showed a normal appendix, inflamed right fallopian tube with serosanguineous fluid in the pelvis. The anterior surface of the liver was inflamed and covered with haemorrhagic exudate.

QUESTION 2

This is a case of perihepatitis associated with pelvic inflammatory disease, known as Fitz-Hugh-Curtis syndrome (FHC). The patient was treated with tetracycline and metronidazole. Her abdominal pain settled dramatically in 24 hours and she was discharged home in the third postoperative day.

Discussion

The cause of right-sided abdominal pain in a fertile woman is sometimes difficult to diagnose, especially if it is not associated with classical symptoms and signs. The association between pelvic inflammatory disease (PID) and perihepatitis was first described by Curtis in 1930,1 followed by Fitz-Hugh in 1934.2 The syndrome is more commonly observed nowadays, a phenomenon directly associated with the increasing incidence of PID.3

Initially, FHC syndrome was seen as a result of gonorrhoeal infection. Recently, Chlamydia trachomatis infection has been found to play a more significant role.4 In the acute stage petechial haemorrhages and fibrinous exudate are observed on the liver surface and pelvic organs. This leads to adhesions within the pelvic organs and between liver surface and surrounding organs (violin-string adhesions).5 Different mechanisms have been postulated for the extension of pelvic infection to the liver capsule, including transcoelmic spread via the right paracolic space, retroperitoneal lymphatic and haematogenous spread.6 It was suggested that chlamydial perihepatitis may be due to a hyperimmune reaction.7

The classic presenting symptom is pleuritic right upper abdominal pain with possibly bilateral upper abdominal pain and tenderness in the presence of acute or subacute PID.8 The clinical diagnosis can be difficult and other causes of right-sided abdominal pain have to be excluded. Cultures of the endocervix for C trachomatis and Neisseria gonorrheamay be difficult and a negative culture does not exclude the diagnosis since the sensitivity of a single culture is limited.

Serologic evidence of acute chlamydial infection can be obtained by demonstrating the presence of IgM antibody, a rise in antibody titre in serial sera, or a very high titre of IgG antibody.4Laparoscopy plays an essential role in the diagnosis of atypical abdominal pain. Perihepatitis cannot be diagnosed with certainty unless it is directly visualised.7

The findings in cases of FHC syndrome range from haemorrhagic appearance of the liver, to dense adhesions between the liver and surroundings associated with inflamed fallopian tubes.5Antibiotic therapy specific for the possible causative organisms (C trachomatis, gonococci and anaerobes) gives a dramatic response; a combination of tetracycline (or doxycycline) and metronidazole provides excellent coverage.3

Learning points

  • a high index of suspicion of FHC syndrome should be considered in cases of right-sided abdominal pain in sexually active young women

  • laparoscopy is essential for the diagnosis of atypical abdominal pain and may reveal rare causes

Final diagnosis

Perihepatitis associated with pelvic inflammatory disease (Fitz-Hugh-Curtis syndrome)

References

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