Monday, October 27, 2008

Violin Strings

A 20 year old woman presents with sudden onset severe right upper quadrant abdominal pain radiating to the shoulder and pleuritic chest pain. She also complains of lower abdominal discomfort for the last few days that is worse with sexual activity and jarring movement. She just finished her last menstrual period. She does not use barrier contraception and has multiple sexual partners.

On exam, you note marked RUQ tenderness as well as diffuse lower quadrant tenderness with decreased bowel sounds and rebound tenderness. Unfortunately, she refuses a pelvic examination.

She was diagnosed with cholecystitis. On laparoscopic approach, you see the following image at the liver:

Challenge: I guess it's not cholecystitis. What's the diagnosis?

Image shown under fair use.


Alex said...

fitz curtis hugh syndrome

Craig Chen said...

yes! great eponym question but rarely in real life
Violin Strings

This is Fitz-Hugh-Curtis syndrome or perihepatitis, an infection of the liver capsule and peritoneal surfaces of the anterior right upper quadrant, leading to classic “violin string” adhesions. Urogenital Chlamydia trachomatis infections account for 90% of the cases. The lower abdominal symptoms are characteristic of pelvic inflammatory disease; a pelvic examination would find purulent endocervical discharge with acute cervical motion and adnexal tenderness with bimanual examination.

Sources: UpToDate;