Liver Pain Location, Symptoms, Tests and Causes

The term liver pain is often used to describe right upper quadrant pain or more specifically pain in the right hypochondrium of the abdomen. The are many causes of pain in this region but is often attributed to the liver since it occupies most of the space within this quadrant.

Medical terms for liver pain, like hepatalgia or hepatodynia, are rarely used since it is difficult to isolate whether the pain stems directly from the liver or from the surrounding structures. Therefore, the term liver pain is used to describe any pain in the right upper abdominal quadrant (more anteriorly) when there is known liver disease. Often pain in the RUQ which occurs more posteriorly is referred to as kidney pain due to the proximity of the structure to the posterior wall of the lower chest cavity/upper abdomen (i.e. back).

Location of Liver Pain

The liver, although the largest organ in the body and weighing a significant 1.5kg in adults, can tuck almost entirely under the right ribcage when supine (lying flat). Upon standing or erect, the liver shifts down lower within the abdominal cavity. It is also pushed down during deep breathing by the contracted diaphragm.

However, the liver is not isolated to the right side of the abdomen. Due to its size, it extends across the midline of the body, through the epigastrium (upper middle part of the abdomen) to lie partly in left hypochondrium (left upper quadrant/LUQ).

Symptoms associated with Liver Pain

In liver disease resulting in pain, some of the following signs and symptoms may also be present :

• Itchy skin
• Jaundice
• Enlarged or shrunk liver (identified upon clinical examination/CT/MRI scan)
• Abdominal swelling (either due to enlarged liver or ascites)
• Unintentional weight loss
• Fever
• Dark urine and pale stools
• Fatigue
• Dry mouth and eyes

In severe cases of liver disease, the following may be present :

• Dizziness
• Flapping tremors
• Mental features like confusion

In addition, other signs and symptoms may include :

• Ascites
• Diarrhea
• Nausea and/or vomiting
• Signs of mineral and/or vitamin deficiencies
• Impaired blood coagulation (clotting)
• Changes in blood glucose levels
• Changes in blood pressure

Many of these signs and symptoms are non-specific. If a liver-related disorder is suspected, blood tests may help to assess the liver functions and possibly identify the most likely causes.

Tests and Investigations

Blood Tests

The most common test conducted to assess the health of the liver is the liver function test (LFT). Despite its name, it is not a true reflection of the functioning of the liver but rather an indicator of  biochemical markers which arise with liver cell damage.

An LFT will detect the levels of :

• Alanine aminotransferases (ALT) / Aspartate aminotransferase (AST)
• Alkaline phosphatase (ALP)
• Gamma-glutamyl transferase (GGT)

Depending on the laboratory, tests to monitor the level of the following may be conducted simultaneously :

• Albumin
• Bilirubin
• Prothrombin time (PT)

In addition, the following tests may also be considered in chronic liver disease :

• Alpha1-antitrypsin
• Ferritin
• Hepatitis B surface antigen
• Hepatitis C antibody
• Liver autoantibodies (antinuclear factor, smooth muscle antibody, antimitochondrial antibody)
• Immunoglobulins
• Caeruloplasmin

Non-specific tests like a CBC (complete blood count), total protein and lactase dehydrogenase (LDH) may also be conducted.

Imaging

The following imaging techniques may be used to identify changes in the liver size, any fatty deposits, nodules, cysts or masses.

• Ultrasound
• CT / MRI
• Cholangiography
• Magnetic resonance cholangiopancreatography (MRCP)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Liver biopsy

Causes of Liver Pain

Most liver conditions itself will not result in pain especially in the early stages. Often pain in the upper abdomen, which seems to be related to the liver, is due to neighboring structures. Therefore disorders affecting the following structures need to be excluded :

• Kidney – particularly the right kidney (refer to kidney pain location), often due to kidney stones, infections.
• Gallbladder –  gallbladder stones (biliary colic), bile duct stones, inflammation of the gallbladder (cholecystitis) or ducts (cholangitis) due to infectious or non-infectious causes.
• Pancreas – particularly pancreatitis and tumors
• Colon – intestinal spasms, constipation, diverticula, inflammatory bowel disease
• Stomach – gastritis, ulcers, gastroenteritis
• Duodenum – inflammation, ulcers, infections
• Abdominal wall pain and back pain may also need to be taken into consideration

As mentioned above, most liver conditions do not cause liver pain.  Even the more common infectious and inflammatory conditions may be painless despite the presence of other signs and symptoms of liver disease.

Abdominal tenderness is more likely to be present than pain itself. This painless presentation may occur in the more common conditiosn like :

• Alcoholic liver disease
• Non-alcoholic fatty liver disease
• Acute liver failure
  
• Cirrhosis – pain is almost never present unless there is some other cause related to the cirrhoisis
• Hepatitis , infectious and non-infectious, will develop later especially in HBV

Pain in the liver is more likely to arise from less common conditions like :

• Liver abscess
• Hepatocellular carcinoma, especially with large tumors
• Secondary malignant tumors
• Benign tumors, like hepatic adenomas
• Hepatic cysts, including cysts in the bile duct
• Hydatid cysts due to Echinococcus graulosus infection
• Intrahepatic cholestasis
• Hepatic arterial occlusion
• Portal vein thrombosis
• Hepatic vein obstruction like Budd-Chiari syndrome
• Acute fatty liver of pregnancy
• Hemochromatosis

Any pain arising outside the liver (extrahepatic) even within the biliary tree are attributed to other conditions.