Saturday, November 20, 2010

Hepatitis C : Liver Pain

Answer: While the liver does indeed reside on the right side of the abdomen, with its bulk under the ribcage, pain in this area is not necessarily from the liver. There are several potential sources of pain in this part of the body. The gallbladder sits in a pocket surrounded by liver, and often can cause crampy intermittent pain when gallstones are present. The large intestine makes a sharp bend just under the liver in an area called the hepatic flexure. Gas can become trapped in this area and cause severe intermittent pain. If the liver becomes enlarged, the stretch of its capsure can cause a dull aching pain that is almost constant. Furthermore, the muscles of the rib cage can become torn or irritated and cause pain. A careful physical exam by an experienced physician can often separate these entities out.
Fatty Liver
(Steatosis or Steatohepatitis)
Fatty liver refers to the infiltration of triglycerides and other fats into the liver cells, causing abnormal liver tests, inflammation and possibly permanent liver damage when left untreated. Because of improved imaging tests and frequent blood testing, fatty liver is now being diagnosed more frequently and non-alcoholic steatohepatitis (NASH), a form of fatty liver, has become the third most common liver disease in U.S. adults who are evaluated for increased liver enzymes.
While patients don't usually experience symptoms from fatty liver, it can be detected through an ultrasound or CT scan and by elevation in liver chemistries.
Occasionally, patients may experience a dull pain in the right upper abdomen or fatigue. To make an absolute diagnosis, a liver biopsy is performed.
Patients who suffer from abdominal discomfort or pain often undergo an ultrasound and/or CT scan to evaluate this complaint. In many cases, the cause of the symptoms is found by the imaging exam. In other cases, the problem is not found and other tests must be done to pinpoint the source of the symptoms.
Finally, in a few cases, abnormalities may be found that are probably not the cause of the patient’s pain. Liver cysts frequently fall into this category. In most cases, liver cysts are benign and do not cause pain or other symptoms.
However, in rare cases, patients may experience pain due to liver cysts that are infected or malignant. Also, even benign cysts can cause pain or discomfort in the right side of the abdomen when they grow to large sizes or if they spontaneously bleed internally.
Doctors should evaluate your pain in relation to the location of the possible liver cyst to determine whether there may be a connection. Other symptoms such as fever, vomiting or jaundice might also provide clues. Blood tests could be done to check for elevated levels of liver enzymes. If there is still uncertainty, then further tests (such as MRI or a liver biopsy) might be needed. You should follow up with a gastroenterologist experienced in liver disease for more definitive evaluation. Still, remember that most patients who have small liver cysts on CT scans have no symptoms as a result of these cysts.
Pain or discomfort usually refers to the pain in the upper right quadrant of the stomach. This pain also sometimes occurs in the right upper back and scapular area. The nature of the pain is usually a dull sensation combined with a subtle discomfort, which makes the patient actually become aware of the existence of the liver organ. This is a common symptom of chronic hepatitis, especially if there are problems in the gall bladder, such as gallstones or inflammation.
The liver parenchyma itself has no sensation, but the liver membrane, which forms a capsule covering the actual liver, is sensitive. When the liver becomes inflamed, conditions such as blood congestion, cell swelling (liver), increased secretion and retention of bile, and liver cell necrosis all increase the pressure to the liver membrane. This in turn causes the dull pain or discomfort in the liver area. During palpation, this area will also feel tender.
The gallbladder is actually the more frequent the cause of this symptom since anatomically, gallbladder is literally “buried” in the lower surface of the liver. The gallbladder is sensitive to inflammation, pressure, and chemical stimulation, and can cause cramping, burning, and pricking pain. Since about 50% of chronic hepatitis patients have gallbladder problems, pain that originates in the gallbladder are often mistaken as liver pain. In order to find out whether the problem is in the gallbladder, an ultrasound examination may be necessary.
If inflammation or small gallstones (less than 2 cm in diameter) are causing the gall bladder pain, if the gallstones are large, then surgery may be needed to remove the stone(s) or the entire gall bladder.
This pain is usually more obvious during acute episodes of chronic hepatitis.
Once the inflammation activities have been brought under controlled, the pain in the area should be reduced dramatically or be completely eliminated. However, sometimes sensations of pain will continue to exist even when the causes in the liver or gallbladder are controlled. Pain triggers in the brain may cause this phenomenon after a case of long-term chronic pain.
Pain and Risk factors

By Mayo Clinic staff
Each underlying problem that can lead to enlarged liver has a distinct set of risk factors.
For example: Alcohol abuse.
Men are more likely to abuse alcohol than women are. The risk of alcoholism is higher if you have a family history of the disease.
Depression and anxiety also increase the risk of alcohol abuse.
Nonalcoholic fatty liver disease.
Being overweight or obese is a major risk factor for nonalcoholic fatty liver disease. Having diabetes or abnormal cholesterol levels also increases the risk.
Hepatitis A.
You’re at increased risk of hepatitis A if you travel to or work in regions with high rates of hepatitis A. You’re also at risk if you’re a sexually active gay or bisexual man, you use illicit drugs, you work in a research setting where you may be exposed to the virus or you have hemophilia or receive clotting-factor concentrates for another medical condition.
Hepatitis B.
You’re at increased risk of hepatitis B if you have unprotected sex with more than one partner, you have a sexually transmitted disease, or you share needles during intravenous drug use. You’re also at risk if you live with someone who has a chronic hepatitis B infection, you have a job that exposes you to human blood or you received a blood transfusion or blood products before 1970.
Hepatitis C.
You’re at increased risk of hepatitis C if you inject or snort illicit drugs, you received an organ transplant before 1992, you’ve been exposed to infected blood or you received clotting factor concentrates before 1987. You’re also at risk if you have hemophilia and received blood products before 1992 or you’re receiving hemodialysis for kidney failure. Heart failure. Various factors increase the risk of heart failure, including high blood pressure, coronary artery disease, diabetes, kidney failure and congenital heart defects. Liver cancer. Chronic infection with hepatitis B or C is the most important risk factor for liver cancer. Cirrhosis — an irreversible scarring of the liver — diabetes, smoking and excessive alcohol consumption may increase risk as well.
published online 09 September 2010.

"Choledocholithiasis is the presence of a gallstone in the common bile duct. The stone may consist of bile pigments or calcium and cholesterol salts.
Alternative Names
Gallstone in the bile duct; Bile duct stone; Bile calculus; Biliary calculus"
Background & Aims:
We assessed the temporal relationship between abdominal pain and elevation in liver function tests (LFTs) in patients with acute symptomatic choledocholithiasis.
Retrospective study of patients that presented within 12 hours of pain onset and were subsequently found to have choledocholithiasis.
We identified 40 patients with complete medical records. Levels of aspartate and alanine aminotransferases (AST and ALT) correlated with duration of pain (Pearson correlation, r = 0.633 and 0.622 respectively, P < .001 for both); the correlation was not as strong for γ-glutamyl transpeptidase (GGT) (r = 0.326, P = .046) and was not significant for alkaline phosphatase or bilirubin. This temporal association was stronger in patients that had undergone cholecystectomy versus those with intact gallbladders (for ALT, r = 0.603 vs r = 0.311, respectively). Eighteen patients, evaluated within 6 hours of pain, had normal or minimal alterations in LFTs; transabdominal ultrasound was abnormal in 6 (sensitivity 33.3%). All had repeat LFTs within 24 hours (mean 10.3 ± 6.9 hours later) and large increases in ALT and aspartate aminotransferase levels (mean 10.5- and 6.8-fold respectively; P < .01 for both), intermediate increases in glutamyl transpeptidase levels, (mean 4-fold, P < .05), and no changes in alkaline phosphatase levels. This significant increase in LFTs was the only indication of biliary pathology before endoscopy in 11/18 patients.
Increasing duration of pain is associated with increasing LFTs (particularly transaminases) in patients with acute symptomatic choledocholithiasis. Patients with normal LFTs and ultrasound upon presentation should have repeat LFTs if biliary pain is suspected. The absence of significant biochemical abnormalities within the first 24 hours makes the diagnosis of symptomatic choledocholithiasis unlikely.

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