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Age-Related Factors
Rates of FHCS are higher among adolescent females than adult women with
PID.
The higher rates among adolescents may be related to their immature cervical
ectropion (presence of columnar cells on the ectocervix), making them
biologically more susceptible to cervicitis.
Epidemiology
The incidence of FHCS (perihepatitis in presence of PID) is higher among adolescent
girls (27%) when compared to adult women (413.8%).
Risk Factors
Those factors which place an individual at risk for acquiring a genital infection with
Chlamydia or Gonorrhea resulting in pelvic inflammation:
Unprotected intercourse
Early sexual debut
Pathophysiology
The pathophysiology of this disorder is poorly understood, but the following
mechanisms have been proposed (some with conflicting or controversial
evidence, and maybe with different mechanisms in operation for Chlamydia
vs. Gonorrhea):
o Direct bacterial spread from the fallopian tubes to the liver via the
pericolic gutters:
Higher anti-Chlamydial IgG titers have been found in those with both
perihepatitis and salpingitis than with salpingitis alone.
Associated Conditions
PID
Salpingitis
Diagnosis
Signs and Symptoms
History
The acute phase is characterized by:
o Sharp, pleuritic pain located in the RUQ of the abdomen, or pain
referred to the ipsilateral shoulder
o
Review of Systems
May be associated with nausea, vomiting, hiccups, fever, chills, malaise, or signs of
salpingitis (lower abdominal pain and abnormal vaginal discharge)
Physical Exam
No pathognomonic exam findings, making FHCS a diagnosis of exclusion
Examination will demonstrate RUQ tenderness, or rarely a friction rub is
heard over the same area.
Tests
Laboratory tests and imaging studies are often nonspecific.
Labs
Liver enzyme levels: Typically, normal, but may be elevated. (Transaminase
elevations are more likely in the setting of gonococcal rather than Chlamydial
perihepatitis.)
ESR and/or C-reactive protein may be elevated.
If high clinical suspicion for STDs exists, samples should also be obtained
from the rectum, urethra, and pharynx.
Obtain studies to rule out other gastrointestinal or renal causes of RUQ pain:
Amylase, lipase, stool guaiac, and urinalysis/urine culture.
Imaging
Imaging studies are useful in ruling out or eliminating other potential causes of
RUQ pain.
Chest and abdominal radiographs to evaluate for pneumonia or
subdiaphragmatic free air:
o
Differential Diagnosis
FHCS can mimic other conditions making the diagnosis difficult.
Cholelithiasis/cholecystitis
Pneumonia
Pulmonary embolism
Pyelonephritis
Hepatitis/Peritonitis
Nephrolithiasis
Subphrenic abscess
Pancreatitis
Appendicitis
Herpes zoster
Infection
C. trachomatis is more likely to be the etiologic agent than N. gonorrhea, although
both have been implicated in FHCS.
Treatment
General Measures
Antibiotic therapy is indicated in the management of FHCS.
The same agents directed against Chlamydia and Gonorrhea are used to treat
PID and FHCS.
One should not await confirmatory lab results to treat if clinical suspicion is
high.
Sexual activity should be avoided until 1 week after both the patient and
partner(s) have completed treatment.
P.109
Medication (Drugs)
Treatment regimen as per CDC Guidelines for treatment of PID
Oral regimens:
Parenteral regimens:
o
Followup
Disposition
Hospital admission criteria for FHCS are similar to those for PID and include:
o Inability to rule out a surgical emergency
Pregnancy