Pain from the liver, biliary and pancreatic systems
Pain originating from the liver, biliary tree or pancreas is usually felt in the upper third of the abdomen. The features of the pain that should be elicited in the history are the same as those for abdominal pain.
This is usually felt in the right upper quadrant of the abdomen, right loin or epigastrium. It may radiate through to the back. The pain is due to stretching of the liver capsule following recent swelling of the liver, as caused by right heart failure and acute viral or alcoholinduced hepatitis. It is typically a dull, constant, aching pain. Liver metastases may also cause pain as a presenting feature, especially in later stages. Associated symptoms may include nausea and jaundice.
Biliary colic is the term used to describe the pain due to obstruction of the biliary system, for example by a stone. The patient complains of very severe constant pain with excruciating colicky spasms felt in the upper abdomen, which may radiate to the back or right subscapular region. The onset is sudden, often after a meal (postprandial) or at night and the pain usually lasts up to 2 or 3 hours without relief except with strong analgesia. Associated features commonly include nausea, vomiting and sweating. Jaundice occurs in about a fifth of patients.
Acute cholecystitis, when the gallbladder becomes inflamed due to infection, causes more well-localised, constant pain as the parietal peritoneum becomes involved. The patient complains of pain in the right hypochondrium, which often radiates to the right shoulder tip. The pain is exacerbated by movement and breathing and persists until analgesia is given, and the underlying cause is treated. Unlike biliary colic, the pain lasts more than 3 hours. Associated symptoms include fever, nausea, vomiting and anorexia.
Gallstones may also cause postprandial indigestion or pain, usually with an onset up to half an hour after eating, lasting 30 minutes to 1.5 hours. It is often worse after fatty foods, and symptoms may recur over several months to years .
Inflammation of the pancreas, as occurs in acute pancreatitis, causes epigastric pain which is often sudden in onset, constant and increasing in severity. The pain may radiate through to the back and towards the left shoulder. Movement and lying down exacerbate the pain and characteristically patients prefer to sit up and lean forwards. Commonly there is persistent nausea, with retching and vomiting. Strong analgesia is required.