In the outpatient clinic for a long time, many patients often describe discomfort in the right hepatic area, especially those with hepatitis B or C. They think it is a manifestation of liver cancer and are often nervous and can’t stand it, which seriously affects their life and work. Is this really the case? What is the real situation, and how to correctly view right hepatic discomfort and related diseases? Here are a few aspects to elaborate on the pain in the liver area and related diseases.
A. Etiology of right hepatic discomfort
1, the onset of hepatitis: is the right quarter rib spontaneous pain, mainly acute hepatitis or chronic hepatitis acute attack patients due to liver congestion, swelling, exudation and hepatocyte necrosis, liver peritoneal stimulation nerve after the production of swelling, dull pain or pinprick-like pain, physical examination patients often complained of tenderness or percussion pain.
2.Chronic liver disease or cirrhosis: toxic hepatitis induced by drugs or toxins, cirrhosis, liver abscess, amebic liver disease, liver cancer, etc.
3.Biliary system lesions: cholelithiasis, biliary infection (including bacteria, fungi, parasites, stones, metabolites, etc.), bile duct cancer, etc.
4.Non-hepatobiliary system diseases
(1), chest wall lesions: such as local injury to the muscles of the right quarter rib, rib fracture, chest wall contusion, costal chondritis, osteomyelitis, herpes zoster, intercostal neuritis, chest wall tuberculosis, etc.
(2), pleural and lung tissue lesions: such as right-sided tuberculous pleurisy, pneumothorax, pus thorax, hemothorax, pneumonia, bronchopulmonary cancer, pulmonary embolism, etc.
(3), other: such as subdiaphragmatic abscess, etc.
Main symptoms
Different patients with liver disease have different manifestations in the liver area, and there are various triggering causes: they often feel pain like pins and needles in the liver area, or stuffy discomfort, sometimes or not, as if something is attached to it. Some patients may have radiation to the left side or to the back of the shoulders, feeling heavy in the back.
A small number of patients with liver disease may also feel significant pain in the liver area, but this type of pain is rarely caused by chronic liver disease. Pain or tenderness in the right upper abdomen usually occurs in the acute phase of liver disease, e.g., acute viral hepatitis. It also occasionally occurs in the abrupt phase of chronic liver disease, but such abruptness is uncommon. If the liver is always painful and intense in one place, other causes must be considered, more likely post gallstones, cholecystitis, and very rarely, possibly liver cancer (mostly advanced).
Third, the basic mechanism of the formation of liver area pain
Pain in the liver area is an early warning mechanism of inflammation in the liver area, which stimulates the nervous system. It is known that there is no nervous system in the liver, so intrahepatic hemangiomas, cysts, calcified foci, intrahepatic nodules, etc. do not induce the manifestation of pain. Because the nerve tissues of the nervous system cross each other, the area of pain in the liver is not necessarily limited. Therefore, pain will be felt only when inflammation, mechanical obstruction, tumor enlargement and other factors stimulate the peritoneum of the liver or the bile duct and gallbladder system.
4.Detection of the cause of liver pain
1.Imaging test Color ultrasound is the easiest way to detect pain in the liver area and make differential diagnosis, which is good for identifying cholecystitis, gallstones, hemangioma, etc. Of course, it is also good for diagnosing liver cancer. MRI is of course better, including SCT, but is expensive and not conducive to routine physical examinations. Gastroscopy is also of high value to distinguish gastritis from other inflammatory diseases.
2, biochemical tests liver function, AFP, CEA test is very practical, inexpensive and effective, conducive to the identification of the presence of tumors and the occurrence of hepatitis.
Routine blood and urine tests are easy to determine whether there are bacterial and viral infections and whether they are combined with other diseases, etc.
Not all liver pains are liver disease attacks or liver cancer
Liver pain is a fairly common clinical symptom, but it is not the “patent” of liver disease. In clinical encounters with patients complaining of hepatic pain, the following diseases are generally taken into consideration, i.e., the basic principle of starting from the most common to the rare diseases.
Biliary tract diseases are the most common, including cholelithiasis, biliary system infection (tumor, bacterial or non-bacterial inflammation, parasites, etc.), cholecystitis or postoperative complications of the gallbladder (biliary tract), etc. Among them, cholecystitis is the most common cause, because 80% of patients with chronic liver disease are combined with cholecystitis, so pain in the liver area is the most common. Because of the anatomical location close to the liver, there is often “hepatic pain”. The more obvious cholecystitis pain site is more fixed, limited, dull pain or colic attacks, B ultrasound can mostly diagnose, that is, ultrasound suggests inflammatory changes in the gallbladder, but mild cholecystitis only mild symptoms, slight discomfort, ultrasound is not easy to detect; but there are many ultrasound suggests inflammatory changes in the gallbladder, no clinical symptoms.
2, hepatic gastropathy gastritis chronic liver disease patients are often combined with gastritis, accounting for about 70% of the total, sometimes also respond to discomfort in the liver area or the right quarter rib area, in addition to painful sensations, often accompanied by fullness and discomfort, belching sensation.
3, right diaphragmatic pleural lesions, rare. Patients with cirrhotic ascites are often combined with pleurisy, which is usually an inflammatory adhesion of tuberculosis or non-tuberculosis. It can be expressed in the medical history, chest X-ray can show signs of lesions, liver function tests and ultrasound examination of the liver are not abnormal. Such adhesions cause “hepatic pain”, which is mostly vague or dull pain.
4. Right lower thoracic rib margin disease, mostly seen. Mostly seen in costochondritis. These disorders have obvious local pressure points, typically with rib cartilage elevation. The pain increases with coughing and deep breathing, and should not be missed if not neglected during physical examination. Of course, liver function and liver ultrasound are normal.
5, right upper rectus abdominis segment strain, more common, commonly in drivers and ambulatory workers, etc. resulting in the right upper rectus abdominis segment in a state of contraction fatigue. The signs are surface pressure pain, which is more obvious when bending over, and completely different from visceral pain.
6.Hepatocellular liver cancer or gallbladder (bile duct) cancer, which is rare. Early stage hepatocellular liver cancer (bile duct cancer) does not have any clinical appearance and does not induce pain in the liver area because it is located in the liver. Only intermediate and advanced hepatocellular carcinoma will be painful after touching the peritoneum of the liver due to its large size. If the tumor is located close to the peritoneum, the pain in the liver area is relatively mild or does not occur when the tumor is small, but as the tumor grows, the pain in the liver area becomes more and more intense, and the pain is often unbearable in the later stage and lasts longer.
Treatment of liver pain
The basic principle: check first, treat later, pay attention to the regulation and reduce the use of drugs.
1. Pain in the liver area in liver disease generally does not require painkillers. After completing the aforementioned examination and determining the cause, most of them will disappear gradually as the liver disease gets better through rest, reasonable nutrition and appropriate treatment. Therefore, we still emphasize “three parts treatment, seven parts nourishment”.
2, pain is also related to the individual sensitivity of each person, so it does not necessarily need to be treated in all cases of liver pain, should consult a doctor according to the specific circumstances, for further examination, except for other diseases. When the pain in the liver area is obvious and affects work and study, it can also be treated for different causes, including liver-clearing and bile-suppressing drugs for cholecystitis, proton pump inhibitors for gastritis, and drugs to promote digestive power; if necessary, consult the appropriate specialist for treatment.
3.Liver pain can still appear during or after the recovery period of some liver diseases, and it is intermittent or paroxysmal, which is one of the manifestations of “post-liver disease syndrome”, and it is also one of the functional injuries, which can be gradually reduced and relieved by the doctor’s guidance. Further examination should be conducted to exclude other diseases.