The liver is the largest organ in the body. It appears as a reddish-brown, cone-shaped organ, which is located at the right upper quadrant of the abdominal cavity, just below the diaphragm and above the stomach, intestines, and right kidney. It weighs approximately 3 pounds. 
Picture 1: Anatomy of Liver
Liver plays a vital role in our body. It is referred to as one of the most hardworking organs since it has over 500 functions that it performs every day to keep the body functioning properly . Here are some of the major functions of the liver:
1. Fat metabolism
- Bile production: The bile produced by the liver aids in breaking down fats in digestion which occur at the small intestine.
- Production of cholesterol and proteins which are essential for the transport of fats throughout the body. 
2. Protein Synthesis
- Control the production of amino acids. Amino acids are the building blocks of proteins.
- Manufacture proteins which are responsible for blood plasma.
- Protein production for transport of fats in the body
- Manufacture proteins which play a role in blood clotting [1, 3]
3. Carbohydrate metabolism
- Liver is involved in the breakdown, production, and storage of carbohydrates.
- Liver also functions for the conversion of excess glucose to glycogen for storage. Then, it is converted back to glucose for providing energy when needed by the body. [1, 5]
4. Hemoglobin processing
- Involves decomposition of red blood cells
- Liver aids in processing hemoglobin to produce iron [1, 3]
5. Filter, Detoxification, and Waste Elimination
- The major function of the liver is the filtration of the blood that comes from digestive system prior to its circulation through the body.
- Also, the liver plays a role in breaking down the dangerous substances in the body. The end-product of this procedure is eliminated by the body into the bile or blood. The bile, together with the waste products, enter the digestive tract, and exits the body through feces.
- Converts ammonia to urea: Urea is the waste product coming from the protein metabolism. This is eliminated in the urine.
- Chemical detoxification
- Drug metabolism
- Removal of bacteria from the body, resulting to better immunity against infections. [1, 4]
What is Liver Pain?
Liver pain refers to the pain felt at the right upper quadrant or right hypochondriac portion of the abdomen . This is usually described as heavy, dull, and steady kind of pain . Also, liver pain may be felt as severe and sharp in character that generally occurs with back ache. The liver pain results when the pain receptors covering the organ’s capsule are pressed .
The other terms used for liver pain are “hepatodynia” or “hepatalgia”. These two terms are rarely used nowadays. This is due to the fact that when this kind of pain occurs, it is hard to pinpoint the source of pain, whether it comes from the liver or from its surrounding organs. 
Picture 2: Liver Pain
Characteristics of Liver Pain
- Patients with liver pain may also experience accompanying dyspnea or difficulty of breathing.
- Abdominal pain located at the right side is aggravated during inhalation or coughing.
- Liver pain may be characterized by the occurrence of abdominal pain plus pain radiating to the shoulders or back.
- Vague and dull aching pain felt at the right upper portion of the abdomen
- Severe, sharp, and stabbing kind of pain 
Where is Liver Pain Located?
- The location of the liver pain may be hard to determine because the brain perceives it occurring at the abdomen as a vague and dull kind of pain. Distributed across the liver capsule (covering) are the pain receptors of liver. When pressure is exerted on the surface of the liver capsule, it also puts pressure on the liver pain receptors. This leads to the brain’s perception of pain present at the liver.
- The pain, brought about by the pressure on the liver pain receptors, is felt at the right upper portion of the abdomen, usually below the ribcage.
- Most of the time, liver pain is confused with abdominal pain which is generalized on the whole area. Also, the kidney pain which is described as back ache may be interchanged with liver pain. There are also instances that liver pain radiates to the right shoulder.
- Pain located at the right upper quadrant is also commonly associated with gall stone formation, pancreatitis, and other disorders of the abdomen.
- Since liver pain may be misidentified for other disorders or diseases, seeking medical advice is a must. This is to ensure that correct diagnosis will be made. [3, 8]
Picture 3a : Abdomen divided broadly into 4 quadrants : right upper, right lower, left upper and left lower
Image Source : Adam Inc.
Picture 3b : Liver location in relation with the abdominal nine quadrants
Image Source : instruct.uwo.ca
Picture 3c : Liver location in relation with abdominal organs ( Note: In picture – S.I – small intestine and L.I – large intestine)
Image Source : instruct.uwo.ca
Liver Pain Causes
There are various causes and factors that lead to the occurrence of the liver pain. Most of these causes are directly associated to the organ . Alcoholism is one of the major factors that contribute to the occurrence of different liver diseases. Long term alcoholism leads to the inflammation of the liver, and later on, liver cirrhosis . Here are various factors and causes of liver pain:
1. Liver disorders
- Fatty Liver Pain: Excessive build up of fats in the liver causing its inflammation.
- Liver Cirrhosis: Usually brought about by over-consumption of alcohol
- Alcoholic Liver Disease
- Hepatitis: Inflammation of the liver caused by viral infection
- Liver Failure: This results from exposure to toxic substances, drugs’ side effects, as well as viral infections.
- Liver Cancer [3, 11]
2. Metabolic Disorders
- Glycogen Storage Disease
- Wolfman Disease
- Weber Christian Disease
- Gallstones 
- Pneumonia [3, 11]
Fatty Liver Pain
Fatty liver pain is the condition wherein there is an excessive accumulation of fats or triglycerides in the liver. These triglycerides are the most common fats that are present in the body. These also contain lipids which are essential for energy and cell repair.
Normally, the body obtains triglycerides from the product when food is metabolized by the liver. Then, the triglycerides bind to certain proteins producing lipoproteins and later on circulates throughout the body. When there becomes an anomaly in the transport of lipoproteins or triglycerides, it will build up in the liver. 
The accumulation of fats in the liver will result to liver inflammation (hepatitis) and inflammation of its nearby tissues and organs. When this condition is untreated or undetected, the organ’s size may increase and causes it to malfunction, resulting to fatty liver pain.
The fatty liver pain is usually felt at the right upper quadrant of the abdomen. This is characterized as a dull ache in the initial stages of the disease but as it progresses, patients may feel it as sharp and severe pain. For patients with this kind of pain, medical attention should be sought immediately. The effects of mild to severe liver failure may cause extensive damage to the body. 
Picture 4: An illustration of the spectrum of Non-Alcoholic Fatty Liver Disease (NAFLD)
Liver Pain Symptoms
There are various liver pain symptoms that may manifest. In the beginning some of these symptoms may go unnoticed . Also, many patients just ignore the presence of these initial symptoms not until they experience severe pain .
The following are the initial symptoms that accompany the occurrence of liver pain
- Skin itching
- Yellowish discoloration of the skin and eyes (Jaundice)
Picture 5: How a person with jaundice looks like
- Ascites (Abdominal Bloating)
- Dryness of the eyes and mouth
- Presence of hepatomegaly (enlarged liver) or shrunk liver: Detected through CT Scan/MRI
- Weight loss 
For patients with severe conditions of liver disease, these may manifest
- Mental changes such as confusion
- Tremors characterized as flapping 
Other symptoms include
- Dark circles surrounding the eyes
- Increased perspiration
- Halitosis (Bad breath)
- Strong odor of the body
- Reddish appearance of soles and palms
- Nausea and vomiting
- Tachycardia (fast heart rate) 
Differential Diagnosis of Liver Pain
The correct diagnosis of liver pain must be determined, to start early treatment and prevent possible complications. 
1. Blood Tests
- Liver Function Test: This is performed to assess the overall health status of the liver. It includes detection of the levels of alanine aminotranferase (ALT), gamma-glutamyl transferase (GGT), and alkaline phosphatise (ALP).
- Monitoring of the levels of bilirubin, albumin, and prothrombin time
- Liver Enzyme: Blood tests and urinalysis are used to determine the level of liver enzymes such as SGPT and SGOT
- Detection of alpha fetoproteins [3, 6]
Picture 6: Blood Sample used for Liver Function Test
2. Imaging Studies
- If the doctor suspects that the liver pain is associated with various symptoms, ultrasound and endoscopy, may be done to examine the severity of liver scarring and liver cirrhosis.
Picture 7: Illustration of the Endoscopy Procedure
- Liver Biopsy: A sample of liver tissue is taken for examination to diagnose liver disease.
Picture 8: Illustration of how liver biopsy is done
- CT Scan/ Magnetic Resonance Imaging (MRI)  and 
Liver Pain Treatment and Remedies
Patients who are experiencing severe liver pain should immediately go to the hospital for emergency help. This would include patients who are having symptoms such as blood in the vomitus. On the other hand, patients with mild symptoms should still go see a doctor for early diagnosis and prompt treatment. Different treatment and remedies for liver pain is based on the determined cause of the pain. 
1. Lifestyle modification
- Refrain from the agents that are proven to be the cause of the liver pain
- Includes avoiding alcoholic beverages and drug abuse 
2. Diet Modification
- Increase in water intake
- Reduce intake of sodium
- Consumption of fruits and vegetables
- Whole food supplements  and 
- Antiviral agents, Flagyl, Adefovir, 3TC
- Medicines for electrolyte and water replacement
- Morphine: This is advised for patients who have severe liver pain. This is given in correct titrated doses.
- High dose steroids: Dexamethasone is given at least 8mg every day. The purpose of steroids is to decrease edema and pressure on the liver pain receptors. [7, 11]
- This is performed for removing gallstones to relieve liver pain
- Liver Transplant: This is last resort when all other treatment has failed. [3, 11]
5. Herbal Detoxification
- This uses natural herbs to eliminate the toxins that have accumulated inside the body. 
by on in Liver and Gallbladder