Abdominal Pain and Liver Disease

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Abdominal Pain and Liver Disease

When diagnosed with hepatitis, patients often expect to feel pain over the liver. And, in fact, many people with chronic hepatitis do experience abdominal pain or discomfort over the liver. Others state that although they do not actually experience pain, they do feel a vague sense of “fullness”, or an “awareness”, of the liver. However, patients who report these symptoms to the doctor, will likely be informed that the liver itself does not typically cause pain or discomfort. Abdominal pain and/or pain over the liver (known as right upper quadrant pain), in people with liver disease may have many causes. This type of pain should not automatically be attributed to a liver disorder – other causes should be investigated. In fact, abdominal and right upper quadrant pain is rarely due to chronic liver disease. In this article, parts of which are excerpted from my book – “Dr. Palmer’s Guide to Hepatitis and Liver Disease”, I will discuss some of the

causes of abdominal pain in people with liver disease.

Right upper quadrant pain, when due to the liver, occurs most commonly in the acute stages of liver disease, (inflammation of the liver that lasts less than six months), or during a flare - up of a chronic liver disease. In these circumstances, the cause of this pain is due to acute inflammation, irritation, and distention of the liver’s surface. Otherwise, the liver is rarely tender.

Gallstones as the name suggests, are stones that form in the gallbladder. The gallbladder is a pear-shaped organ that is nestled beneath the liver (see figure 1). Its main function is to store and concentrate bile - a bitter greenish mixture of acids, salts and other substances. Approximately twenty million Americans have gallstones. Gallstones often occur in individuals with liver disease, especially those with cirrhosis. Other risk factors for gallstones include female gender, obesity, a family history of gallstones, multiple pregnancies, rapid weight loss, and biliary tract narrowing (known as biliary strictures). The typical pain from gallstones is a right upper quadrant discomfort that usually lasts from a half hour to six hours before abating. Pain is usually severe and usually recurs. This pain often radiates to the shoulder or back, and is usually accompanied by nausea and vomiting. Diagnosis of gallstones

is typically made by obtaining an abdominal sonogram. People with symptomatic gallstones require surgical removal of the entire gallbladder, not just the gallstones. This is known as a cholecystectomy, and is usually performed by a surgeon using a laparoscope (a type of endoscope inserted through a small incision in the abdominal wall). This is known as a laparoscopic cholecystectomy. There is no medication that can be recommended for the treatment of gallstones. Ursodeoxycholic acid ( Actigal or Urso) had been used in the past to dissolve some small gallstones, but their recurrence was common, and in most cases, surgery was eventually required. Gallstones can sometimes fall out of the gallbladder into the bile ducts – the passageways connecting the liver and the gallbladder, which carry bile into the intestines. Blockage of a bile duct is a serious complication, resulting in jaundice, excruciating pain and infection. Thus, if one is

suffering from abdominal pain due to gallstones, surgery is typically recommended. Prevention of gallstones is difficult if a person is prone to forming them. However, avoidance of rapid weight loss, and maintenance of a low fat diet with lots of vegetables may help.

Liver cancer may also cause abdominal or right upper quadrant pain. People with a history of chronic hepatitis B or C, and those with cirrhosis due to any chronic liver disease are at risk for developing liver cancer, (also known as hepatocellular carcinoma, (HCC) or hepatoma). HCC is one of the most common cancers in the world, with its greatest frequency occurring in Asia and Africa. Although its rate of occurrence has been rising over the past twenty years in the United States, it is still uncommon, accounting for only 0.5 to 2 percent of all cancers. The cause of this rise has been linked to the prevalence of chronic hepatitis C in the United States.

The risk of developing HCC in people with cirrhosis is between one to six percent per year. The risk of developing HCC differs somewhat depending upon the cause of cirrhosis. For example, individuals with chronic hepatitis B have a high risk of developing HCC in their lifetime, up to 200 times the risk that the general population has. Furthermore, HCC can occur in people with chronic hepatitis B even in the absence of cirrhosis. Individuals with chronic hepatitis B who drink excessive amounts of alcohol have been found to develop HCC on average more than ten years earlier, than those who do not drink alcohol excessively. Therefore, people with chronic hepatitis B should avoid all alcohol, as it can speed the progression to HCC.

In contrast to hepatitis B, cirrhosis is typically present in all cases of hepatitis C -associated HCC. It appears that a co- infection with both hepatitis B and C greatly increases a person’s chance of developing HCC. Therefore, obtaining the hepatitis B vaccination is crucial for people with chronic hepatitis C who are not already infected with hepatitis B. It usually takes more than thirty years from the time one becomes infected with hepatitis C for HCC to develop. It has been demonstrated that treatment with the drug interferon prior to the development of HCC actually lowers the incidence of HCC in some individuals with chronic hepatitis C. This underscores the importance of early recognition and treatment of chronic hepatitis C in the early stages of disease. Individuals with hepatitis C who drink alcohol excessively appear to have a greater risk of developing HCC, underscoring the importance of total

abstinence from alcohol in people with chronic hepatitis C.

HCC may be diagnosed via a combination of blood work, imaging studies and often a liver biopsy. However, by the time abdominal or right upper quadrant tenderness occurs, the tumor is usually large and may have already spread to other parts of the body rendering a poor prognosis. A discussion of the treatment options for HCC is beyond the scope of this article and readers are referred to my book for additional information.

Stomach disorders, such as peptic ulcer disease (PUD) and gastritis (inflammation of the stomach lining) often cause abdominal pain in people with liver disease. An upper endoscopy (a procedure wherein a flexible tube with a light at the end is inserted down the esophagus into the stomach and first part of the small intestine) is typically performed in order to diagnose these stomach disorders. During an upper endoscopy, a biopsy is usually taken of the lining of the stomach for Helicobacter pylori, a bacteria which may cause gastritis and ulcers. These stomach ailments are readily treatable with medications known as proton-pump inhibitors, such as Prevacid, Nexium or Aciphex, either alone, or in combination with antibiotics, depending upon the precise diagnosis.

Intestinal pain must also be considered as a cause of abdominal or right upper quadrant pain. The right side of the large intestine lies in close proximity to the liver, and the transverse colon lies in the middle of the abdomen (see figure 1). Therefore, abdominal and right upper quadrant pain may be due to spasms of the intestines. This symptom, which is characteristic of irritable bowel syndrome (IBS), is often mistakenly attributed to the liver. IBS is a benign digestive disorder, which most commonly occurs among young women, but it can also occur in men and older women. The symptoms of IBS, such as abdominal pain and cramping, bloating, and excessive gas, are often successfully treated with anticholinergic medications such as Librax or Donnatal, when combined with dietary restrictions and stress reduction. A colonoscopy (a flexible tube with a light at the end used to visualize the large intestine) may need to be performed

in situations in which abdominal pain does not abate and remains unexplained. Other more serious disorders of the intestines that may cause abdominal and right upper quadrant pain may be discovered during a colonoscopy, such as Crohns disease (an inflammatory disease that may effect the small and/or large intestine), or colon cancer. In fact, as a general recommendation, it is important for everyone over the age of fifty to obtain a colonoscopy.

Other causes of abdominal and right upper quadrant pain which should be investigated in people with liver disease, include inflammation of the pancreas a condition known as pancreatitis, which may occur with increased frequency in those who drink excessive alcohol, and scar tissue from prior abdominal surgery known as adhesions.

If one experiences abdominal pain along with distention and swelling of the abdomen, ascites must be considered as a cause. Ascites is characterized by accumulation of fluid in the peritoneal cavity – the space between the abdominal organs and the skin, and is the most common complication of cirrhosis. When this is accompanied by a fever and severe abdominal pain, an infection of this fluid should be suspected. This is a serious medical condition known as spontaneous bacterial peritonitis (SBP), and requires immediate hospitalization and treatment.

However, abdominal distention and pain occurring in patients with liver disease may be due to less serious ailments than ascites. For example, abdominal distention and discomfort can result when the digestive tract fills with gas. When this happens, one may experience the sensation of being bloated. This type of abdominal distention may be due to impaired or inadequate absorption known as malabsorption or digestion, known as maldigestion, of certain foods which can be associated with certain liver disorders. This is a controllable condition, and may be treated by the avoidance of specific foods, for example milk-products or wheat (gluten) products.

From reading this article, you have learned that the causes of abdominal and right upper quadrant pain are numerous and varied. Therefore, if you experience these symptoms, it is important to bring them to the attention of your doctor, and not automatically assume that your liver is the cause of your discomfort. For additional information on abdominal pain you may wish to consult my book. Until next time - continue to keep up the fight for a healthy liver.

Portions of this article were reprinted with permission of the author Palmer, MD from the book "Dr. Palmer's Guide To Hepatitis and Liver Disease". © Copyright Palmer, MD 2000/2004 copyright ©. For further information please visit Dr. Palmer’s website - www.liverdisease.com.