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PRIVATE EM WRITES
A non-surgical emergency condition
presents with severe right upper quadrant abdominal pain
Dr LAM Ka Keung
Chairman of Private Fellows’ Chapter, HKCEM
Consultant, Hong Kong Baptist Hospital, 24-hour Out-patient Clinic
A thirties’ year old lady complained of severe right upper quadrant pain, low grade fever and nausea. She also complained of mild pelvic pain a few days prior to this attendance. Physical examination revealed normal vital signs except body temperature of 38°C. There was localized tenderness and guarding at the right lower quadrant of abdomen with Murphy’s sign positive. Although there was no history of gallbladder disease, she was admitted with provisional diagnosis of acute cholecystitis. Blood test showed raised white cell count; while liver and renal function, amylase and glucose levels were normal; beta-HCG level was below 2.3IU/L.
Urgent CT studies showed a thin enhancement at the inferior liver capsule, and small amount of rim-enhancing fluid in the pelvic cavity suggesting pelvic inflammatory disease. Gynecologist was consulted and diagnosis of bilateral pyosalpinx complicated with peri-hepatitis (Fitz-Huge-Curtis syndrome) was made. She was treated with intravenous antibiotics and laparoscopic drainage of abscess. High vaginal swab yielded Streptococcus agalactiae. She had good recovery and was discharged days after operation.
Enhancement at inferior liver capsule suggestive with peri-hepatitis. Together with pelvic infection, the diagnosis was Fitz-Hugh-Curtis syndrome.
Few days later, a very similar case of 20's years old was admitted for pelvic inflammatory disease. She also complained of severe right upper quadrant abdominal pain. Subsequent investigations revealed mildly deranged liver function test and thickened bilateral fallopian tubes. Although CT scan did not show liver capsule enhancement, laparoscopy found adhesions over liver capsule that was compatible with Fitz-Huge-Curtis syndrome.
Thickening of fallopian tube suggestive of hydrosalpinx. The rim enhancing structure was a corpus luteal cyst.
Inflammation at the liver capsule produced severe right lower quadrant abdominal pain that drove our mind towards the common gallstone diseases. Diagnosis of PID in this presentation is challenging: reviewing clinical history, gynecologist consultation in negative upper abdominal ultrasound or directly to CT. Management of pelvic infection accordingly and symptomatic relief are the treatments needed.
Reference: Kiyoshi S, Masatomi I. FItz-Hugh-Curtis syndrome. BMJ 2019;12:10.1136
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