Discussion
Imaging findings were suggestive of pelvic inflammatory disease (PID) associated with focal perihepatitis.
Fitz Hugh Curtis syndrome (FHCS) was proposed by Curtis in 1930 as a rare clinical condition, with accompanying PID, characterized by inflammation of the perihepatic capsule, without involvement of the hepatic parenchyma. The perihepatitis evolves to fibrous adhesions, also called a “violin-string appearance”, between the surface of the liver and the abdominal wall [1].
This syndrome has been reported between 4% and 27% of patients with PID [2]. Currently C. trachomatis is considered the main causative pathogen, although in the past it was more frequently associated with gonococcal infections [3].
The typical symptoms are abdominal pain, which can be severe on respiration, fever and urinary symptoms, such as frequency and residual sensation [4].
FHCS can be classified into acute phase and chronic phase according to the pathologic changes of perihepatitis. Acute clinical phase is characterized by exudative inflammation of the hepatic surface, capsular congestion, oedema, punctuate haemorrhage and fibrinous exudation. In the chronic phase, local or diffuse thickening of the hepatic capsule and adhesions between the surface of the liver and the abdominal wall can be observed [5, 6]. Hepatic capsular enhancement due to increased blood flow or inflammation at the hepatic capsule has been reported as a pathognomonic sign of the acute phase of FHCS on contrast-enhanced CT [4, 6]. For this reason arterial phase scan can significantly increase the sensitivity and the accuracy of diagnosing FHCS.
The persistence of capsular enhancement on the delayed images may reflect early events in capsular fibrosis. Other CT findings of this entity are the following: thickening of the hepatic capsule, large loculated perihepatic fluid collection, transient hepatic attenuation difference and gallbladder wall thickening.
Some authors classified the thickening of hepatic capsule in following types: local type (length < 5 cm) or diffuse type (length >5 cm), depending on the extent, and string type (capsular thickness of 1–2 mm), broadband type (≥3 mm for capsular thickness) and mixed type (including string type and broadband type) in terms of the appearance [7].