Physical examination

Quadrant (abdomen)

Surgery

Vomiting

Psychiatry

Sign (mathematics)

Radiology

Emergency department

Mathematics

Internal medicine

Mathematical analysis

Nausea

Medicine

Abdominal pain

Gastroenterology

Question: A 19-year-old woman presented to our emergency department with acute abdominal pain, nausea, and vomiting. She had no previous medical history. She denied drug abuse, lead poisoning, allergies, abdominal injury, or psychiatric problems. She was febrile, but her vital signs were normal. On physical examination, she exhibited severe tenderness of the epigastrium with guarding and right upper quadrant pain with positive Murphy’s sign. Ultrasound examination and enhanced computed tomography scans were performed (Figure A, B, yellow arrow). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Laboratory examination results revealed elevated C-reactive protein level of 4.11 mg/dL (reference range, 0–10 mg/dL) and white blood cell count of 9270 /μL. Enhanced abdominal computed tomography scans revealed hepatic capsular enhancement of the right lobe in the arterial phase. Subsequently, endocervical swab culture and a urine polymerase chain reaction for Chlamydia trachomatis were positive. Based on the clinical and radiographic findings, we made a diagnosis of Fitz-Hugh-Curtis syndrome (FHCs). FHCs is a rare, inflammatory disease of the liver capsule that is a potential complication of pelvic inflammatory disease. The main causal micro-organisms of FHCs are C trachomatis and Neisseria gonorrhoeae.1Theofanakis C.P. Kyriakidis A.V. Fitz-Hugh-Curtis syndrome.Gynecol Surg. 2011; 8: 129-134Crossref Scopus (9) Google Scholar Symptoms of FHCs are often vague and nonspecific, including acute onset of severe abdominal pain in the right upper quadrant, fever, nausea, vomiting, indigestion, and poor appetite. These symptoms are similar to those of other disorders and FHCs is sometimes confused with acute cholecystitis, cholelithiasis, pleurisy, pulmonary embolism, and pyelonephritis. Thus, symptoms are often overlooked. Hepatic capsular enhancement on enhanced computed tomography scanning is a very specific finding of FHCs.2Nishie A. Yoshimitsu K. Irie H. et al.Fitz-Hugh-Curtis syndrome. Radiologic manifestation.J Comput Assist Tomogr. 2003; 27: 786-791Crossref PubMed Scopus (58) Google Scholar The long-term complications of FHCs are associated with pelvic inflammatory disease, and include chronic abdominal pain, small bowel obstruction, infertility, and ectopic pregnancy.3Ricci P. Sola V. Pardo J. Asymptomatic Fitz-Hugh-Curtis syndrome: three cases of incidental diagnosis during laparoscopy.J Obstet Gynecol. 2008; 28: 352-354Crossref PubMed Scopus (12) Google Scholar Early identification of FHCs can reduce serious complications. Thus, clinicians should consider HFCs as a possible differential diagnosis in young women with severe abdominal pain in the right upper quadrant.

Right Upper Quadrant Pain With Positive Murphy’s Sign in a 19-Year-Old Woman