Hepatobiliary Conditions: Signs, Symptoms & Pain

• Jaundice is first evident in the sclera of the eyes

Signs and symptoms of Hepatoiliary Conditions

• Skin changes can include yellow, orange, or greenish discoloration, pallor, pruritus, bruising, spider angiomas, and palmar erythema (liver palms), which may also report throbbing or tingling of the hands
• Nail changes can include white nails of Terry, leukonychia (white bands across the nail plate), clubbed nails, and koilonychia (spoon nails – concave nail bed)
• Musculoskeletal (MSK) symptoms can occur as the only presenting symptom or in combination with systemic signs/symptoms
• Pain associated with hepatic and biliary systems may present as thoracic pain between the scapulae, right shoulder pain, right upper trap pain, right interscapular pain, and right subscapular areas

Systemic Cause & Location of Pain

• Liver disease can cause pain in the thoracic spine (T7-T10; midline to right side) and right upper trapezius and shoulder
• Gallbladder issues can cause pain in the right upper trapezius and shoulder, as well as in the right interscapular area (T4-T8)

Cholelithiasis

• The formation of gallstones that vary in shape and size
• May consist of cholesterol and bile pigment or mixed content with calcium salts
• Small stones may be silent and excreted in bile
• Larger stones obstruct bile flow in cystic or common bile ducts, causing severe pain, often referred to the subscapular area
• Risk factors include being female (2x as likely), high cholesterol, obesity, multiparity, use of oral contraceptives or estrogen supplements, hemolytic anemia, alcoholic cirrhosis, and biliary tract infection
• Obstruction of a duct by large calculi causes sudden, severe waves of radiating pain, often with nausea and vomiting
• Pain continues, and jaundice develops, bile backs up into the liver and blood, posing a risk of ruptured gallbladder if obstruction persists; pain decreases if the stone moves into the duodenum
• Surgical intervention may be required
• Solid material (calculi) forms in the bile, potentially obstructing the biliary tract

Cholecystitis

• Is the inflammation of the gallbladder and cystic duct

Hepatitis

• Is the inflammation of the liver, which can be alcoholic (often with fatty liver), idiopathic (also with fatty liver), or viral (local infection or infection elsewhere in the body)
• Other causes include infectious mononucleosis and chemical or drug toxicity
• Signs and symptoms include a preicteric (prodromal) stage with fatigue, malaise, anorexia, nausea, and general muscle aching
• The icteric stage includes the onset of jaundice, light-colored stools, darker urine, and a tender, enlarged liver with mild aching pain
• The posticteric stage is a recovery stage with reduction in symptoms, but weakness persists for weeks

Cirrhosis

• Is progressive destruction of the liver
• Causes include alcoholic liver disease, biliary cirrhosis (associated with immune disorders), post-necrotic cirrhosis (linked with chronic hepatitis or long-term exposure to toxic materials), and metabolic disorders (usually genetic)
• Extensive diffuse fibrosis interferes with blood supply and may cause bile backup, leading to loss of lobular organization
• Degenerative changes may be asymptomatic until the disease is advanced
• Liver biopsy and serologic tests are used to determine the cause and extent of damage
• Functional losses include decreased inactivation of hormones and drugs, requiring careful monitoring of drug dosages, decreased removal of toxic substances, and reduced bile entering the intestine, impairing digestion and absorption
• Bile backup leads to obstructive jaundice, and blood flow blockage occurs through the liver, leading to portal hypertension and congestion in the spleen, increasing hemolysis
• Inadequate storage of iron, congestion in intestinal walls and stomach (impairing digestion and absorption), and development of esophageal varices (leading to hemorrhage) can also occur
• Development of ascites (fluid accumulation in the peritoneal cavity) causes abdominal distention and pressure; decreased production of blood-clotting factors; impaired glucose and glycogen metabolism; and impaired conversion of ammonia and urea also occur
• Initial manifestations are often mild and vague, including fatigue, anorexia, weight loss, anemia, and diarrhea
• Dull aching pain may be present in the upper right abdominal quadrant
• Advanced cirrhosis includes ascites and peripheral edema, increased bruising, esophageal varices (which may rupture, leading to hemorrhage and circulatory shock), and jaundice with encephalopathy

Liver Cancer

• Hepatocellular carcinoma is the most common primary liver tumor, more common in cirrhotic livers, but it can also be secondary to metastatic cancer
• Initial signs are mild and general, and diagnosis usually occurs with advanced stages
• Pain over the liver, especially after exercise (hepatitis), and RUQ pain associated with right shoulder pain are common symptoms
• Both RUQ and epigastric pain may occur

Gallbladder Pain

• RUQ of abdomen
• RUQ pain may be associated with right shoulder pain
• Back pain between scapulae which can occur alone as the primary symptom

Common Bile Duct

• Epigastrum: heartburn (choledocholelithiasis)
• RUQ pain may be associated with right shoulder pain
• Both may be associated with back pain between the scapulae

All Pain

• Pain may be referred to the right side of the midline in the interscapular or subscapular area
• Anterior rib pain (soreness or tenderness) at the tip of the 10th rib (less often, can also affect ribs 11 + 12) is possible
• Aggravating activities include respiratory inspiration and eating

Key Points to Remember

• Primary signs and symptoms of liver diseases vary, including GI symptoms, edema/ascites, dark urine, light-colored or clay-colored feces, and right upper abdominal pain
• Skin changes are common, such as pruritus, jaundice, pallor, orange or green skin, bruising, spider angiomas, and palmar erythema
• Intense exercise should be avoided when the liver is compromised
• Severe liver dysfunction can impair peripheral nerve function, potentially causing neurologic symptoms like confusion, muscle tremors, asterixis, and balance/gait impairments
• Referred shoulder pain may be the only presenting symptom of hepatic or biliary disease, often presenting as right shoulder/scapular and/or upper midback pain of unknown cause without limited or painful shoulder motion
• Gallbladder impairment can present as a rib dysfunction with tenderness anteriorly over the tip of the 10th rib (occasionally ribs 11 and 12 area also involved)

Psychoneuralimmunology

• Relates the enteric system, immune system, and brain
• Notes that 2/3 of all immune activity occurs at the gut, linking it to disorders like fibromyalgia, SLE, RA, and CFS conditions

GI Disorders

• Can refer pain to regions mimicking MSK issues
• Gl conditions can refer pain to the back and shoulder, specifically upper back pain (peptic ulcers, pancreatitis, pancreatic cancer)
• Arthritis and migratory arthralgias occur in ~25% of patients with Crohn's disease
• Appendicitis, Crohn's, and UC can cause iliopsoas muscle abscesses, leading to hip, thigh, or groin pain
• Antibiotics and NSAIDs are common meds that induce GI symptoms

Gl Manifestations

• Abdominal pain
• Dysphagia (difficulty swallowing)
• Odynophagia (painful swallowing)
• GI bleeding (emesis, melena)
• Symptoms affecting eating include anorexia and nausea or vomiting
• Arthralgia
• Early satiety with weight loss
• Constipation
• Diarrhea
• Fecal incontinence
• Referred shoulder pain
• Epigastric pain with radiation to back
• Neuropathy

Anorexia / Vomiting

• Can be signs of a GI disorder or other conditions (systemic infection; uremia; emotional responses; motion sickness; elevated ICP; overindulgence of food, drugs; pain)
• Can have serious complications (dehydration, acidosis, malnutrition)

Nausea

• An unpleasant subjective feeling that can be stimulated by distention, irritation, or inflammation of the digestive tract, smells, visual images, pain, and chemical toxins/drugs

Vomiting

• May be triggered by distention or irritation in the digestive tract, stimuli from various parts of the brain, response to unpleasant sights or smells, ischemia, pain or stress, vestibular apparatus, increased ICP, or stimulation of the chemoreceptor trigger zone
• Presence of blood:
• Hematemesis: coffee-ground vomitus indicates action of HCl on hemoglobin; hemorrhage shows red blood
• Bile from the duodenum
• Deeper brown color indicates content from lower intestine
• Recurrent vomiting of undigested food indicates a problem with gastric emptying or infection

Diarrhea

• Is excessive frequency of stools, usually loose or watery
• Can be acute or chronic
• Develops frequently with nausea and vomiting when infection or inflammation
• Common types include large-volume (secretory or osmotic) watery stool - result of increased secretions into the intestine from the plasma, often related to infection, and small-volume diarrhea - results from inflammatory bowel disease, may contain blood, mucus, pus, and and be accompanied by abdominal pain;

Steatorrhea

• Is fatty diarrhea
• It manifests as frequent bulky, greasy, loose stools with a foul odor
• A characteristic of malabsorption syndromes (ex: Celiac disease, cystic fibrosis), and may affect with digestion of macronutrients (fat) and result is abdominal distension

Blood in Stool

• May occur in normal stools, diarrhea, constipation, tumors, or an inflammatory condition
  • Frank blood:
    • Red blood usually from lesions in the rectum or anal canal
• Occult blood:
  • Small, hidden amounts, detectable with a stool test, that may be caused by small bleeding ulcers
• Melena:
  • Dark-colored, tarry stool and may result from significant bleeding in the upper digestive tract

Gas

• Develops normally due to swallowed air, bacterial action on food, and certain foods or alterations in motility
• Excessive gas as eructation (burping), borborygmus, abdominal distention, and flatulence

Constipation

• Less frequent bowel movements that normal result in small and hard stools
• It may be acute or chronic and may be caused by decreased peristalsis
• Chronic constipation may cause by weakness of smooth muscle, inadequate dietary fiber, lack of hydration, failure to respond to defecation reflex, immobility, medications, or obstructions

Visceral Pain

• Causes burning sensation and occurs with inflammation and ulceration in GI tract
• Dull, aching pain is typical result of stretching of liver capsule,
• Cramping can be results of the inflammation, distension, which stems from Colic by an action of recurrent smooth muscle

Somatic Pain

• Receptors directly linked to spinal nerves that cause reflex spasm of overlying abdominal muscles
• Steady, intense, often well-localized pain or involve inflammation of parietal peritoneum

Malnutrition

• Limited malnutrition is generally related to a specific problem, ex: Vitamin B12 deficiency,
• General malnutrition more results from systemic conditions with a presentation of anorexia, vomiting, diarrhea

Dysphagia

• Causes difficulty swallowing, pain, inability to swallow, or neurologic deficits

Esophageal Cancer

• Causes significant dysphagia and occurs with upper back pain
• Poor prognosis from inflammation and smoking/alcohol

Hiatal Hernia

• Part of stomach protrudes into thoracic cavity
• Food may lodge in pouch of stomach which may cause pain/inflammation

GERD

• Periodic inflammation from gastric contents erodes the stomach
• Often conjuncted with hiatal hernia

Acute Gastritis

• Inflamed mucosa and may be ulcerated
• May be from infection, allergies, food sensitivities and alcohol

Peptic Ulcer

• Caused by H. Pylori with gastric ulcers in the stomach
• Breakdown of mucosal barrier can be due to stress, smoking, or alcohol
• Main complication is hemorrhaging

Acute Pancreatitis

• It can quickly damage cells
• The pancreas lacks a capsule
• Inflammation from the pancreas can be destructive

Chemical Peritonitis

Caused by gallstones or abuse to the chemical composition

Risk Factors of Pancreatic Cancer

• Smoking
• Cirrhosis
• Obesity

Celiac Disease

• Genetic
• Defect in intestinal enzyme
• First sign is in stomach due to cereal

Crohn's Disease

• It is autoimmune that may affect digestive tract with skip lesions

Appendicitis

• General, with periumbilical pain
• Can cause testicular/groin pain

General Sign of Diverticular Disease

• Develops on a gap within muscular tissue
• Increased risk with multiple pregnancies

Rectal Signs of Colorectal Cancer

• Hemorrhoids
• Changes Bowel Patterns
• Fatigue

Intestinal Obstruction

• Intestinal contents are unable to move
• Obstacle promotes infection
• Generalized peritonitis

Mechanical Obstruction

• Adhesions that twist organ
• Hernias

Peritonitis

• Causes peritoneal membrane issues
• Chemical peritonitis from ruptures
• Appendicitis
• Gangrene