5Physical Exam Vitals = normal Chest = clear CV = normal Abdo = Tender to direct palpation. RLQ = LLQNo rebound/guarding etc.No mass
6LABS Hgb = N WBC = 13.5 (neuts = 11, monocytes 1.2) Lytes = N BG = N Lipase = N
7LEs…ALP = N (104)ALT = N (16)GGT = 64 (8-35)Bili T = 46 (0-20)Bili D = 24 (0-7)
8Urine dipBeta = negative3+ ketones2+ bilirubinTx—fluids, anti-emetic, booked for abdo u/s in am. Dx “abdo pain NYD/mild LFT abnormality”
9VISIT #2 Returned next day post u/s: “Well seen and NORMAL liver, GB, ducts, pancreas, kidneys, spleen, aorta, para-aorta areas, bowel, uterus, overies, adnexa. No free fluid.”
10Repeat labsBili 29 (down from 46)GGT 56 (down from 64)WBCs 12.2 (down from 13.5)K = 3.4Dx: “gastroenteritis”
11Visit #3 Returns 5 days later… Persistent diarrhea Malaise ABDO PAIN!! 9 lb wt loss in 10 days
12OTHER HX? No travel No well water exposure No recent ABX No sick contactsNo exposure to uncooked meats
13Phx = healthy, no surgeries, PAP 6 months prior was normal No meds (was on OCP in past)Social = infrequent EtOH, no IVDU,No risky sexual behaviour1 partner. Using condoms.Tattoo at end of JuneFam Hx: No IBD
19Fitz-Hugh-CurtisPerihepatitis in association with pelvic inflammatory diseaseOriginally described by Carlos Stajano (1919) in Uroguay.1930’s… re-described by Thomas Fitz-Hugh and Arthur Curtis.
20EtiologyOriginally felt only to be secondary to N. gonorrhea (Fitz-Hugh discovered gram negative diplococci on smears taken from the liver capsule)1970s, Chlamydia trachomatis implicated and remains the most common pathogenCase reports... strept milleri, tuberculosis
22Diagnosis RULING IN pelvic inflammatory disease RULING OUT other causes of RUQ pain +/or elevated liver enzymes
23Pathogenesis Multiple Theories: Direct Infection of Liver? Hematogenous Spread?Lymphatic Spread?Exaggerated Immune Response?
24How Common? Studies show broad ranges 4%-27% of patients with PID RISK FACTORS:IUDs, pelvic surgery, multiple partners, lack of barrier protection etc.
25SymptomsSymptoms of PID (fever, abdominal pain, vaginal discharge, vaginal bleeding)Right Upper Quadrant Pain—usually pleuritic.Possible for patient to present with RUQ pain only (subacute/chronic PID)
26Atypical Presentations Ileus/obstructionPeri-splenitisPeri-appendicitisFitz-Hugh-Curtis in a maleChilaiditi syndromeOvarian CaPerforated UlcerPleural effusion
27Physical Exam Cervical motion tenderness Adnexal/uterine tenderness Lower Abdominal tendernessRUQ tenderness (may occur on its own)+/- friction rub over right anterior costal margin
28Radiographic Studies Ultrasound: Excludes cholelithiasis, cholecystitis etc.Insensitive for FHCMay demonstrate “violin-string” adhesions, loculated fluid in the hepatorenal space.“Violin String” also in Familial Mediterranean Fever, Diaphragmatic Endometriosis
29Radiographic Studies CT Scan: Helpful IF can demonstrate contrast enhancement of the liver capsuleSensitivity of only 28%! (Joo et al. 2007)Depends if biphasic CT vs. portal phase only
30LAB TESTS Liver Enzymes: often normal but can be elevated Litt and Cohen (JAMA, 1978) found ALT most likely, but ‘cholestatic’ enzyme elevations also reported+/- ESR+/- LeukocytosisCultures: N gonorrhea, C Trachomatis from cervix. Cultures from pelvic aspirates tend not to correlate. (mixed anaerobes, aerobes etc.)
31Treatment Similar to that of PID Generally focused on N gonorrhea and C trachomatis, gram negative rods, anaerobesDirect therapy according to culturesDrain abscesses
32PID tx Tx regimens: Ceftriaxone 250 mg IM/Doxy 100 bid x 14 days Levo od/Flagyl bid x 14 daysCefoxitin 2g IV q6/Doxy 100 bidIV for 48 hours afebrile, then POPoor response to ABX = laparoscopy
33Complications Those of PID: Infertility Adhesions Chronic pain Ectopic pregnancyReiter’s syndrome
34Culture results:Streptococcus milleri (heavy)B fragiles (moderate)E. Coli (scant)NAAT:Negative for both Chlamydea and Gonorrhea