36. The Right Upper Quadrant

February 07, 2021


Courtney was Peter’s case. He presented her on rounds one Monday morning.

‘Courtney Hill, 25 years old. She was admitted Sunday due to pain in the right upper quadrant for 2 days.’ He started. ‘Which was accompanied by fever and abdominal distension.’

Courtney was a regular healthy 25-year-old. She worked in a big department store, lived with her boyfriend, and never really had any health problems. But that week the pain started and it bothered her. Whenever she took a deep breath she felt it. While she was doing her job at the store, the pain was also there. She wasn’t too worried though until she spiked a fever on Sunday, her day off, when she went to Brooklyn Hospital.

On her initial assessment, she was in pain but stable. Her abdomen was especially tender in the right upper quadrant, and worsened with inspiration, with a positive Murphy’s sign. Her past medical history was mostly unremarkable: she denied any previous medical conditions, surgeries, or continuous medications. She was a light smoker, was sexually active with her boyfriend, and had regular menses, the last being 2 weeks before.

You can probably guess now that hepatobiliary disease was the number one on Courtney’s differential, more specifically cholecystitis.  So the physicians that looked at her ordered some initial labs. They came back with leukocytosis and increased C-reactive protein, consistent with inflammation, but her hepatobiliary enzymes were disappointedly innocent. Her urinalysis detected 10-20 leukocytes, but no infection. A chest x-ray showed no significant findings, and the abdominal x-ray showed no free air or hydroaeric levels. 

So despite her negative blood work, a hepatobiliary ultrasound was made, and it was also negative for gallbladder disease. However, the liver seemed enlarged with a thickened capsule.

‘I see.’ Dr. Collins said when Peter finished his report of what had happened the day before. ‘And what do you think of her today?’

‘Well, I think her pain seems more under control today.’ He looked at his notes. ‘There was something I noticed, her lower abdomen was also tender to palpation. I asked her about it and she associated it with her menstrual cycles.’

‘That’s interesting, Peter. What else can you tell me about that?’ Lucy proceeded.

‘There’s not much more. She has this light to moderate lower abdominal pain that comes and goes. Oh, and sometimes dysuria.’

‘Okay.’ Lucy joined her hands. ‘We have good things to work with here. I’ll leave it with you two.’ She got up and went to the door. ‘I’ll be back in 10 minutes.’ She winked.

‘Does that mean we’re supposed to solve this until she gets back?’ Peter turned to me.

‘I guess so.’ I smiled. I could never say no to a challenge. ‘Where do we start?’

‘Let's sum it up. Young healthy woman, with well-localized right upper quadrant pain and fever.’

‘Right. What can cause that? Her gallbladder seems innocent, her chest is clean. Liver? Her enzymes are good but what does the thickened capsule mean?’

‘Golden question.’ Peter bit his lip.

‘What about this suprapubic pain? What can it be?’

‘Bowel, bladder, uterus.’ He thought out loud.

‘Wait, that’s something. You said she sometimes has dysuria, but her urinalysis wasn’t suggestive of infection. But some gynecological problems can also cause dysuria. Does she have any other complaints of that sort?’

Peter checked his watch. ‘Do you think there is time for us to ask her?’

‘C'mon.’ I opened the door. ‘After you.’

We hurriedly walked into Courtney’s room. When we got there, Peter started.

‘Hey, Ms. Hill. There are some other things I would like to ask you. The lower abdominal pain of yours, is there anything that makes it worse?’

‘Humm…’ She straightened herself on the bed. ‘It hurts, you know, in intercourse.’ She almost whispered.

‘I see.’ Peter nodded. ‘Do you have any vaginal discharge?’

‘Just the usual, I mean, I haven’t noticed anything different.’

‘Okay. And did you ever go to a gynecologist?’

‘No, never.’ Courtney said. ‘I never really needed it.’

‘And do you use any contraceptive methods?’ I asked behind Peter.

‘No. Tim and I have been trying for a while now.’ She looked down. ‘But I haven’t got pregnant yet.’

‘I am sorry to hear that.’ Peter said. ‘For how long have you been trying?’

‘About a year.’

We left Courtney’s room and went back at a fast pace to meet Lucy.

‘I was wondering where you were.’ She said when we got back. ‘Do you have it already?’

‘PID.’ We both answered together slightly breathless from the walk there.

‘Indeed.’ She smiled at us. ‘When I examined her I also noticed her pelvic pain.’ She gestured for us to sit. ‘So I asked her more about it, and she told me about her dyspareunia and difficulty in getting pregnant and things started connecting. I decided then to perform a brief gynecological exam. What do you think I found there?’

‘Cervical motion tenderness.’ I answered.

‘And maybe some cervical discharge.’ Peter completed.

‘Yes.’ Lucy continued. ‘So as far as we know she has pelvic inflammatory disease. And that can even explain her infertility. But what can we say of her chief complaint?’ She raised one eyebrow.

‘Perihepatitis!’ I answered as it just came to me then. ‘That syndrome related to PID that affects the liver capsule. She even has thickening on the ultrasound.’ At that point, I was just surprised at how obvious it seemed and how I hadn't thought of it until then.

‘Fitz-Hugh-Curtis syndrome.’ Peter seemed to be as shocked as I was.

‘That’s it, kids.’ Dr. Collins got up proudly. ‘A very interesting case. I already ordered the NAAT test so we know which bug is there, but don’t forget to screen for other DSTs as well, Peter.’

‘Will do.’

Her test came back with both Chlamydia and Gonorrhea. We treated her with Ceftriaxone and Azithromycin and her symptoms promptly improved. Besides, a CT scan of her abdomen and pelvis corroborated the diagnosis, showing perihepatic inflammatory stranding, hepatic capsular enhancement, and even a tubo-ovarian abscess with fluid in the pelvis.

Yep, Lucy Collins is that good.

Want to know more about Fitz-Hugh-Curtis Syndrome?


Want to read a real case of Fitz-Hugh-Curtis Syndrome?


Clinical Board

Perit: peritoneal; PID: pelvic inflammatory disease; CMT: cervical motion tenderness;
SS: signs and symptoms; RUQ: right upper quadrant; Dx: diagnosis;
NAAT: nucleic acid amplification test; Tt: treatment.

No comments:

Powered by Blogger.