A man aged 58 years has a history significant for hypertension, obesity, Barrett’s esophagus and reflux. He reports intermittent, dull, right-upper-quadrant (RUQ) pain below the ribs when he lies on his right side. The pain worsens with coughing or inspiration.

Typically, the pain occurs intermittently over a two-week period and then subsides for several weeks before recurring. He is status post cholecystectomy and right hemicolectomy. due to an ileocecal tubovillous adenomatous polyp. The RUQ pain began immediately following the hemicolectomy.

Abdominal and pelvic CT reveals diffuse steatosis of the liver and a small subcapsular area of complete fatty replacement of liver parencyma in the anterior segment of the right hepatic lobe. Although the radiologist believes this occurred after a segmental infarct, possibly related to the patient’s gallbladder surgery, it was not visualized on CT after the procedure. Amylase and lipase are normal, and alanine aminotransferase is slightly elevated (eight points above normal).

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The patient was referred to a surgeon and a gastroenterologist. The specialists did not mention the segmental infarct and offered no explanation for the man’s pain. Could this infarct be the cause? If not, what else should I be looking for? — Dawn Giorgio, PA, Queensbury, N.Y.

Since the RUQ pain is described as chronic rather than acute (as it might be if related to an infarct in the liver), it is probably attributable to fatty liver disease. Having said that, however, the idea that this patient may have had an infarct in his liver needs to be evaluated as well.

Did he have prior ultrasound or CT to determine how long ago this infarct occurred? What risk factors does he have for an infarct (e.g., a recent cardiovascular assault or ischemic event)? Does he have antiphospholipid syndrome?

Other differential diagnoses of the RUQ pain need to be considered, such as sphincter of Oddi dysfunction and adhesions from the patient’s prior right hemicolectomy. — Sharon Dudley-Brown, PhD, FNP-BC, co-director, gastroenterology & hepatology, Nurse Practitioner Fellowship Program, Johns Hopkins University Schools of Medicine & Nursing, Baltimore (157-9)