Many patients in our forums report experiencing right upper quadrant (RUQ) pain. Though NAFLD and NASH are largely asymptomatic, RUQ pain occurs in about one-third of NAFLD/NASH patients and varies in character and severity; some people report a mild aching fullness sensation, while others experience steady sharp pains that can disrupt their sleep.[i] Unfortunately, when patients report RUQ to their primary care providers, routine testing such as bloodwork or an ultrasound may not show anything wrong. With no physical indication that something is wrong or anything identifiable as the issue, pain may go unaddressed for years. If it is addressed, it isn’t uncommon for patients to be referred to psychiatric care, as if the RUQ pain were a symptom of a mental disorder as opposed to a physical disorder like NAFLD. This dismissal of RUQ pain as a symptom is unfortunate and means that the very real pain patients are experiencing is not taken seriously and that fatty liver disease that could have been caught earlier remains undetected.

As doctors always like to remind us, the liver itself has no pain receptors. It has been hypothesized that RUQ pain associated with and near the liver may be caused by distension of Glisson’s capsule, which surrounds the liver and has many pain receptors.[ii] In other words, people who have an abnormally large liver due to inflammation, steatosis, or fibrosis may be putting pressure on the liver capsule, which manifests as pain in the RUQ. As you can see in the microscopic liver picture below, Glisson's capsule is partially highlighted in green, and is a thin layer around the liver.

Though RUQ pain may be a sign of NAFLD or NASH, it may also be caused by other factors, so your doctor may only consider it a symptom if you are also experiencing unexplained fatigue or if you are a member of a population considered high-risk.[iii] That being said, it is one of the two more common symptoms that present in people with any stage of NAFLD/NASH. Even though NAFLD and NASH are mostly asymptomatic, RUQ pain could be a hint that you should consider thinking about your liver.

Some patients who are able to lose weight and reduce steatosis in their liver may experience reductions in RUQ pain as they continue to decrease their stress on the liver. Other patients are successful at losing weight and still experience RUQ pain. On the flip side, people who have been temporarily successful at changing their diets and lifestyles may have reductions in RUQ pain that reemerge when they revert to their old habits. Know that everyone’s bodies react to changes in weight and diet differently, so don’t be discouraged if your RUQ pain doesn’t immediately disappear once you have made lifestyle changes. Remember that lifestyle changes are truly a commitment for life—not temporary or quick fixes.

If you would like to read more about a patient's story involving RUQ pain, check out Terri's cautionary tale by clicking here.

[i] cancertherapyadvisor.com/home/decision-support-in-medicine/gastroenterology-hepatology/nonalcoholic-steatohepatitis-and-nonalcoholic-fatty-liver-disease/

[ii] cancertherapyadvisor.com/home/decision-support-in-medicine/gastroenterology-hepatology/nonalcoholic-steatohepatitis-and-nonalcoholic-fatty-liver-disease/

[iii] https://www.healthgrades.com/right-care/liver-conditions/5-signs-and-symptoms-of-fatty-liver-disease