Liver Pain

Liver, by its name, is known to almost everyone. But, do you know what it actually is? What it does? Or even, where exactly is it positioned inside our bodies? Indeed, it’s a very vital organ for the normal functioning of human body.

The liver, a reddish brown organ, and its supporting organs when diseased leads to a myriad of clinical conditions that can be prognostically very bad. It is important to recognize those conditions early and take appropriate treatment.

To start with, we need to know the basic functions and anatomy of this vital organ ⁽⁶⁾, the largest gland in our body ⁽⁵⁾, the liver.

Main Functions of Liver

• Filtration of blood coming from the digestive tract through portal circulation.
• Detoxification
• Metabolism of medicines and chemicals
• Secretion of bile
• Synthesis of proteins⁽¹³⁾

Liver Location : Where is your liver

Consider a human body. When we remove the limbs, head and neck, what remains is our trunk. The trunk is divided into two parts by ‘Diaphragm’, which is a muscular organ that is vital for breathing. The area above the diaphragm is ‘Thorax’ and below is ‘Abdomen’.⁽¹⁴⁾

Image 1: Position of the liver in a human body. It has two lobes, ie the right lobe and the left lobe. Also note the gall bladder below the right lobe of liver.

Abdomen can be divided in two ways, that is, into 9 regions or 4 quadrants. You can see the divisions in the images given below. The liver is situated in the upper right and left quadrants. Maximum part lies in the right quadrant. Hence, the pain related to liver disorders will mainly occur in the right upper quadrant.

Image 2: Regions of Abdomen. The abdomen is divided into nine regions. Liver can be noticed in Right hypochondriac, epigastric, left hypochondriac and the right lumbar regions. Liver pain is normally felt in Right Hypochondriac or epigastric regions.

Image 3: Quadrants of Abdomen. The abdomen is divided into four quadrants. Liver can be noticed in Right and Left upper quadrants.

Picture : Liver span anatomical surface markings

Liver Anatomy : Where is the liver located

Picture : Liver surface anatomy

Picture : 8 Liver lobes anatomically divided

 

Picture : Liver pain location

Right Upper Quadrant Pain- Causes

The pain in the abdomen can be from the abdominal organs, the peritoneum (a membrane that separates the organs within the abdominal cavity) or extra abdominal organs or tissues.

The character (acute or chronic) and quality (continuous, colicky, dull aching, intermittent) of pain can help in differentiating the causes along with a complete history taking and a proper examination. For the ease of understanding, we can look at the causes of right upper quadrant pain as following.^{(1, 2, 3, 4)}

Abdomen

Organ	Cause	Comments
Vessels & Lymphatics	Mesenteric ischemia Mesenteric adenitis
Liver	Acute viral hepatitis Acute alcoholic hepatitis Mass or swelling in liver Enlarged Liver (hepatomegaly) Budd-Chiari Syndrome Fitz-Hugh-Curtis Syndrome
Gall Bladder	Acute Cholecystitis Cholelithiasis	Gall bladder inflammation Gall bladder stones
Biliary Tract	Acute Cholangitis Choledocholithiasis	Biliary tract inflammation Biliary tract stones
Others	Duodenal ulcers Pancreatitis Colon obstruction Colitis Colonic mass Pyelonephritis Perinephric abscess Nephrolithiasis Sub-diaphragmatic abscess	Infrequent causes of RUQ pain
Abdominal Wall	Cellulitis Herpes Zoster Hematoma or strain of the abdominal muscles

 

 

Peritoneum

Cause	Comments
Intra-peritoneal abscess	Sub-diaphragmatic abscess
Peritonitis	Gall blaader perforation Duodenal ulcer perforation
Intra- peritoneal hemorrhage	Ruptured Abdominal Aortic Aneurysm.

 

Extra Abdomen

Organ	Cause	Comments
Bones	Right sided lower rib fractures Thoracic Spine fracture	It is interesting to note that few structures situated outside the abdomen may also lead to pain in the abdomen. This ‘Referred pain’ can happen when the nerves entering the spinal cord at same level are arising from different locations.
Heart	Inferior wall myocardial infarction.
Lungs	Lower lobe pneumonia Pulmonary Embolism Pleurisy Pneumothorax

Symptoms in Liver disease

• Jaundice
• Right Hypochondriac pain
• Pale stools
• Dark urine
• Swelling in the ankles, feet and abdomen
• Excessive tiredness
• Bruising and bleeding⁽¹⁵⁾

How to differentiate between the causes?

A doctor is necessary to differentiate the cause. It is not unreasonable that abdomen is known as a magic box. A complete care is required in diagnosis of any pain in the abdomen.

A proper and detailed history taking with details such as mode of onset (acute, chronic), history of trauma or abdominal conditions, surgeries, nature of pain, radiation, aggravating and relieving factors, change of pain with posture and breathing, associated features such as fever, diarrhoea, constipation, jaundice, hematuria, dysuria, frequency etc, history of sexually transmitted diseases, vaginal discharge etc can give a jump start to a proper diagnosis.

Physical examination with a detailed eye and ear by inspection, palpation, percussion and auscultation is absolutely necessary to make a working diagnosis.⁽³⁾

Causes of Liver Disease

• Fatty liver disease
• Alcohol abuse
• Liver Cirrhosis
• Viral hepatitis
• Other bacterial, viral, or parasitic infections
• Medicine or chemical related liver toxicities
• Genetic disorders such as Gilbert’s disease, Wilson’s disease, Hemochromatosis
• Cancers of the liver which may be primarily from liver itself or may be secondary deposits from other tissues.^{(6, 11)}

What tests can be expected to be done?

• A complete blood count (CBC)
• Liver function tests
• Kidney Function tests
• Serum Amylase and Lipase
• Urine analysis
• Ultrasonography of whole abdomen with special focus to right upper quadrant.
• CT Scan of abdomen
• HIDA Scan
• X-Ray abdomen in erect and supine postures- To check for free air under diaphragm in cases of perforations of duodenum.
• MRI Scan of abdomen
• Colonoscopy
• Liver Biopsy
• Pregnancy test^{(4, 7, 8, 9, 10, 11, 12)}

What can be done for the treatment of liver diseases?

The treatment for liver pain is to reduce the liver disease. That is chiefly by addressing the specific cause for the disease. But general measures to improve the overall health of liver can be very useful in shortening the disease phase.^{(16, 17)}

• Drink plenty of fluids
• Avoid fatty food.
• Regular exercise.
• Avoid intake of medicines such as Paracetamol/ Acetaminophen.
• Growth or cysts in liver may be treated by a removal.
• In extreme conditions liver transplant may be the only solution.

References:

1. Bengiamin, RN, Budhram, GR, King, KE, Wightman, JM. Rosen’s Emergency Medicine, Molsby Melsevier. 2009.
2. Millham, FH.  Saunders. 2010.
3. Das, S. A Manual on Clinical Surgery, Oxford Handbook. 2001
4. http://www.clinicaladvisor.com/hospital-medicine
5. https://www.healthline.com/human-body-maps/liver
6. https://www.medicinenet.com/liver_anatomy_and_function/article.htm
7. https://patient.info/in/doctor/right-upper-quadrant-pain
8. Cartwright SL, Knudson MP; Am Fam Physician. 2008 Apr 1 77(7):971-8
9. Miller AH, Pepe PE, Brockman CR, et al; 2006 Jan 30(1):69-74.
10. Abdom Imaging. 2003 Sep-Oct 28(5):643-51.
11. Kasper, D.L., et al., eds. Harrison’s Principles of Internal Medicine, 19th Ed. United States: McGraw-Hill Education, 2015.
12. https://www.medicinenet.com/abdominal_pain_causes_remedies_treatment/article.htm
13. https://www.webmd.com/digestive-disorders/picture-of-the-liver#1
14. Netter F. Atlas of Human Anatomy, 3rd edition, Saunders, 2002.
15. https://en.wikipedia.org/wiki/Liver
16. http://www.mayoclinic.org/diseases-conditions/nonalcoholic-fatty-liver-disease/diagnosis-treatment/diagnosis/dxc-20211615
17. https://medlineplus.gov/magazine/issues/spring09/articles/spring09pg25.html