Violin string adhesions in a patient with right upper quadrant pain - which condition is this? 🎻

Those violin-string adhesions are classic Fitz-Hugh–Curtis syndrome, perihepatitis caused by pelvic inflammatory disease (usually Chlamydia trachomatis or Neisseria gonorrhoeae). RUQ pain + normal imaging + violin-string adhesions on laparoscopy = pathognomonic.

This original drawing was created by Arthur Hale Curtis, an American gynaecologist. He described “violin string” adhesions between the anterior liver surface and abdominal wall in 12 female patients with gonococcal salpingitis. This finding was subsequently published in 1930. In 1934, Thomas Fitz-Hugh, an American physician, published another 3 cases attributed to acute gonococcal peritonitis. This later became immortalised as Fitz-Hugh Curtis syndrome (note the placement of the hyphenation and Curtis as the senior author). 📸:

síndrome de Fitz-Hugh-Curtis, la perihepatitis genera adherencias en “cuerdas de violín”, signo clásico.

Bravo! 🎶🙌

🛑 Fitz-Hugh-Curtis Syndrome (Perihepatitis) 🔷️ Complication of PID, most commonly Chlamydia trachomatis 🔷️ Causes RUQ pain that mimics cholecystitis 🔷️ Pain is sharp, pleuritic, worsens with movement 🔷️ Classic finding: “Violin-string” adhesions between liver capsule & abdominal wall 🔷️ Associated with fever, lower abdominal pain, cervical motion tenderness 🔷️ LFTs usually normal (important differentiator) 🔷️ Treatment: Azithromycin or Doxycycline + ceftriaxone for PID coverage.

How does Chlamydia travel all the way to the liver?

@medcrux Direct extension from the right paracolic gutter ??

@medcrux Exactly - it’s a long way to go! 😅

Lupus

Valiant effort but…

@x_hydroberry_x My aunt died of Lupus 2 years ago. I get the reply though. It's really rare.

@x_hydroberry_x Sorry to hear. Lupus can rarely cause lupus peri hepatitis which can mimic this condition, so I stand corrected!

This is of course Fitz-Hugh Curtis syndrome - perihepatitis characterised by violin string adhesions. Usually caused by chlamydia and gonorrhoea infection, this can be seen with other intra-abdominal inflammatory disorders including TB, appendicitis, cholecystitis, endometritis, liver abscess, Crohn’s disease, SLE (lupus perihepatitis). Diagnosis can be elusive as perihepatitis can manifest as a slither of inflammation on the liver capsule that is often missed on imaging (see green arrows below). As such, good history taking, including eliciting risk factors for pelvic inflammatory disease, is key. Laparoscopy remains the gold standard where clinical suspicion is high, enabling for division of adhesions as demonstrated in this video. 📸:

I developed this However I don’t have any of the listed reasons as to why. My surgeon believes it’s a by product of so many abdomen surgeries I’ve had. This shit was VERY painful. Felt like needles poking all my insides. I was told this is very rare to happen in men.

I donno, ask Dr. Paganini, MD, he may know 🎻😅

Sometimes the only option is to cut the strings!

Fitz Hugh curtis syndrome, Doc!

Fastest finger prize! 😜🏅

🥂🍾yey! At last one that I knew 🥳

@drkeithsiau You answered after me 🤷

@drkeithsiau I cède my place to the true victor! 🤗

New fear unlocked

Diagnosis, don't swallow chewing gum.

Pelvic Inflammatory Disease—usually gonorrhea.

🔶Fitz-Hugh-Curtis Syndrome (perihepatitis)- It is a rare complication of pelvic inflammatory disease (PID), characterized by inflammation of the liver capsule without damage to the liver tissue. ∆ Etiology- Mostly caused by sexually transmitted infections like Chlamydia trachomatis & Neisseria gonorrhoeae. 📍C/F- Sharp, pleuritic right upper quadrant (RUQ) abdominal pain worsened by breathing, coughing, movement & may radiate to the right shoulder. •Associated PID symptoms- Lower abdominal pain, fever, vaginal discharge & dysuria. ✓ Dx- Clinical, Laparoscopy shows Inflammation leading to formation of “violin-string” adhesions between the liver capsule (Glisson’s capsule) & the peritoneum or diaphragm. 📍T/t- Antibiotics targeted against STI pathogens (e.g., doxycycline, ceftriaxone) & management of PID.

This is (one of) the reasons it’s so important to treat chlamydia!!

Синдром Фитца-Хью-Кёртиса

Pelvic inflammatory disease (PID) can be complicated by perihepatitis (e.g. Fitz-Hugh-Curtis disease). Patients typically have right upper quadrant pain in addition to classic PID symptoms (e.g. fever, lower abdominal pain), and are young, sexually active, and not using barrier contraception.

Violin-string adhesions = Fitz-Hugh-Curtis syndrome. 🎻 Perihepatitis causing right upper quadrant pain.

Here's my response

Good to see video, I thought only one photo available of this condition 😅

This is like those cut the string machines at the arcade to win a big plushie

ok so im just genuinely curious but also kinda confused.. what am i exactly looking at here? like looking at the comments is it like... the doctors cutting bits off of the liver thats connected to outer skin? i dont understand how this happens. but i would like to know please!

Peri-hepatitis, mostly a Chlamydia causing PID

The reaction of the ladies on my feed is perfect 😂

Fitz-Hugh-Curtis syndrome arises as perihepatitis from pelvic inflammatory disease, most often Chlamydia trachomatis, with normal liver function tests distinguishing it from biliary issues; a 2024 review estimates it in 4% of U.S. PID cases annually. The term originates from Arthur Hale Curtis's 1930 report of adhesions in gonococcal salpingitis patients and Thomas Fitz-Hugh's 1934 cases, with the eponym prioritizing Curtis as senior author despite common misplacement of the hyphen.

adhesions post surgery?

That’s the other possibility! Can also happen with gallbladder inflammation, liver abscess, trauma, atypical infection and even lupus, so not necessary all due to pelvic inflammatory disease.

Does the patient experience immediate relief? ( once he wakes up assuming this is under anesthesia...)

Fitz Hugh Curtis

Fits hurg Curtis syndrome under PID 😜

Questions - do the adhesions for this differ lot visually compared to adhesions caused by endo?

Fitz hugh curtis

🎻 Violin string adhesions + RUQ pain = CHRONIC CHOLECYSTITIS** String-like bands between gallbladder & liver/duodenum on US/CT** 🔍 🎯 Answer: Chronic Cholecystitis**

Fitz Hugh Curtis SYNDROME

Legit didn’t see that coming now I’m replaying it 😆

Cat gut