Fatty liver disease, or hepatic steatosis, occurs when excess fat accumulates in liver cells, affecting a substantial proportion of UK adults. Whilst the location of fatty liver pain is most commonly the right upper abdomen beneath the rib cage, many individuals experience no discomfort at all. The liver itself contains few pain receptors, so when pain does occur, it typically results from liver enlargement stretching the surrounding capsule. Understanding where fatty liver pain is located, what it feels like, and when to seek medical advice is essential for appropriate management and timely intervention.

Understanding Fatty Liver Disease and Associated Discomfort

Fatty liver disease, medically termed hepatic steatosis, occurs when excess fat accumulates within liver cells. This condition exists in two primary forms: non-alcoholic fatty liver disease (NAFLD), which affects individuals who consume little to no alcohol, and alcohol-related liver disease (ARLD), directly linked to excessive alcohol intake. NAFLD has become increasingly prevalent in the UK, affecting a substantial proportion of adults, often associated with obesity, type 2 diabetes, and metabolic syndrome. (Note: you may also encounter the newer terms metabolic dysfunction-associated steatotic liver disease (MASLD) and metabolic dysfunction-associated steatohepatitis (MASH), though UK guidance currently uses NAFLD and NASH.)

The liver itself contains very few pain receptors, which means fatty liver disease is frequently asymptomatic in its early stages. Many individuals remain unaware of their condition until it is detected incidentally through blood tests or imaging performed for unrelated reasons. When discomfort does occur, it typically results from liver enlargement (hepatomegaly) stretching the liver capsule—the thin membrane surrounding the organ—which does contain pain-sensitive nerve fibres.

It is important to understand that simple steatosis (fat accumulation alone) is usually asymptomatic. Most patients with uncomplicated fatty liver experience no symptoms whatsoever. However, as the condition progresses to non-alcoholic steatohepatitis (NASH), where inflammation and liver cell damage occur, some individuals may develop a sensation of fullness or discomfort. Persistent or significant pain in the right upper abdomen should prompt medical evaluation, as it may indicate disease progression, complications, or—more commonly—an entirely separate condition such as gallbladder disease requiring investigation.

Recognising the nature of fatty liver disease helps patients understand why regular monitoring is essential, even in the absence of symptoms. According to NICE guidance (NG49), lifestyle modifications remain the cornerstone of management: achieving gradual weight loss of 7–10% of body weight can improve steatohepatitis and fibrosis; optimising control of diabetes, blood pressure, and cholesterol; and moderating or abstaining from alcohol as appropriate are all key interventions.

Where Is Fatty Liver Pain Typically Located?

When discomfort associated with fatty liver disease does occur, it is most commonly experienced in the right upper quadrant of the abdomen, beneath the rib cage on the right side. This anatomical location corresponds to where the liver sits within the abdominal cavity. The liver occupies a substantial space below the diaphragm, extending from the right side across the midline, with its largest portion positioned on the right.

Patients often describe the sensation as a dull ache, heaviness, or feeling of fullness rather than sharp, stabbing pain. Some individuals report the sensation as a persistent awareness of the area rather than acute pain, which can make it difficult to pinpoint or describe precisely.

The discomfort may occasionally radiate to the right shoulder or upper back due to referred pain patterns. This occurs because the diaphragm, which sits directly above the liver, shares nerve pathways with the shoulder region. When the liver capsule becomes stretched or irritated, these nerve signals can be perceived in distant locations—a phenomenon recognised in hepatobiliary conditions. However, this pattern of referred pain is not specific to fatty liver disease and can occur with other liver or gallbladder problems.

It is crucial to note that pain in the right upper quadrant has numerous potential causes beyond fatty liver disease. Gallstones and gallbladder inflammation (cholecystitis) are common culprits, particularly if discomfort worsens after eating fatty meals—a pattern more typical of biliary disease than fatty liver. Other possibilities include peptic ulcer disease, musculoskeletal problems, or other gastrointestinal conditions. The liver's location means that discomfort in this region requires proper clinical assessment to establish the underlying cause. Self-diagnosis based solely on location is unreliable, and persistent or concerning symptoms warrant medical evaluation to ensure appropriate investigation and management. If you experience right upper abdominal pain that worsens after meals, especially if accompanied by fever or jaundice, seek urgent medical advice as this may indicate gallbladder disease requiring prompt treatment.

Symptoms That May Accompany Fatty Liver Pain

Whilst fatty liver disease often presents asymptomatically, when symptoms do develop, they may include a constellation of non-specific features alongside any abdominal discomfort. Persistent fatigue and general malaise are amongst the most commonly reported symptoms, though these are notoriously difficult to attribute specifically to liver disease given their prevalence in numerous other conditions. Patients may describe feeling unusually tired despite adequate rest, or experiencing reduced stamina during daily activities.

It is important to recognise that unintentional weight loss, loss of appetite, or early satiety (feeling full after eating small amounts) are not typical of simple fatty liver disease and should be regarded as red flags warranting prompt medical assessment. These features may suggest advanced liver disease, such as cirrhosis with complications like ascites (fluid in the abdomen), or may indicate an alternative diagnosis requiring investigation. Nausea, though uncommon in simple steatosis, may emerge as the condition progresses.

As fatty liver disease advances to more severe stages, additional features may manifest. Jaundice (yellowing of the skin and whites of the eyes) indicates significant liver dysfunction and requires urgent medical attention. The development of spider naevi (small, spider-like blood vessels visible on the skin), palmar erythema (reddening of the palms), or easy bruising may suggest progression to cirrhosis. Abdominal swelling due to ascites or peripheral oedema (leg swelling) are concerning signs of decompensated liver disease. Itching (pruritus), dark urine, or pale stools may indicate cholestasis (impaired bile flow) and need prompt evaluation. Confusion or altered behaviour may signal hepatic encephalopathy, a serious complication requiring emergency care.

It is essential to emphasise that most people with fatty liver disease experience no symptoms at all, particularly in early stages. The presence of red-flag symptoms—especially unintentional weight loss, jaundice, or signs of advanced liver disease—necessitates prompt medical assessment. Conversely, the absence of symptoms does not exclude fatty liver disease, which is why screening in at-risk populations and incidental findings on imaging play crucial roles in diagnosis.

When to Seek Medical Advice for Liver-Related Pain

Understanding when abdominal discomfort warrants medical attention is crucial for patient safety. Call 999 or go immediately to A&E if you experience severe abdominal pain, particularly if accompanied by fever, jaundice, confusion, vomiting blood, or passing black, tarry stools. These features may indicate serious complications such as acute liver failure, gastrointestinal bleeding, or infection, which require emergency assessment.

You should contact your GP promptly if you develop persistent discomfort in the right upper abdomen lasting more than a few days, especially if accompanied by unexplained weight loss, persistent fatigue that impacts daily functioning, or loss of appetite. New-onset jaundice, even without pain, requires same-day medical evaluation. Changes in urine colour (dark, tea-coloured) or stool colour (pale, clay-coloured) may indicate biliary obstruction or significant liver dysfunction and should not be ignored. For urgent advice outside normal GP hours, contact NHS 111 online or by phone.

For individuals already diagnosed with fatty liver disease, routine monitoring is essential even in the absence of symptoms. NICE guidance (NG49) recommends regular follow-up for patients with NAFLD, particularly those with risk factors for disease progression such as diabetes, obesity, or elevated liver enzymes. Adults with NAFLD should typically have their risk of advanced fibrosis reassessed at intervals such as every three years, or more frequently if clinically indicated. If you notice any change in your condition—new symptoms, worsening of existing discomfort, or concerns about disease progression—discuss these with your GP rather than waiting for your next scheduled appointment.

Do not attempt to self-diagnose or self-treat liver-related symptoms. If you need pain relief, paracetamol is generally safe when used at the recommended adult dose (maximum 4 grams per day in divided doses). However, never exceed the stated dose, avoid combining with alcohol, and be aware that in chronic liver disease your clinician may advise a lower total daily dose or longer intervals between doses. Avoid non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen if you have cirrhosis or portal hypertension, and seek advice from your GP or pharmacist before using NSAIDs if you have any liver condition. Always discuss any over-the-counter or herbal remedies with a healthcare professional, as some can be harmful to the liver or interact with other medications. Your GP can perform appropriate investigations, including blood tests and imaging, to establish the cause of your symptoms and determine whether specialist referral to a hepatologist is necessary. Early intervention and lifestyle modification can significantly impact disease trajectory in fatty liver disease.

If you experience side effects from any medicine, you can report them via the MHRA Yellow Card Scheme at yellowcard.mhra.gov.uk or through the Yellow Card app.

Diagnosis and Assessment of Fatty Liver Disease in the UK

The diagnosis of fatty liver disease in the UK typically follows a systematic approach aligned with NICE guidance (NG49). Initial assessment begins with a comprehensive clinical history and physical examination, exploring risk factors such as alcohol consumption, body mass index (BMI), presence of type 2 diabetes, dyslipidaemia, and metabolic syndrome. Your GP will palpate the abdomen to assess for hepatomegaly and examine for signs of chronic liver disease.

Blood tests form the cornerstone of initial investigation, including liver function tests (LFTs) measuring alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), and bilirubin. Elevated transaminases, particularly ALT, may suggest hepatic inflammation, though normal values do not exclude fatty liver disease. Additional tests typically include full blood count, glucose or HbA1c (to assess diabetes), lipid profile, and tests to exclude other causes of liver disease such as viral hepatitis (hepatitis B and C serology), autoimmune hepatitis (autoantibodies), and haemochromatosis (ferritin and transferrin saturation).

Risk stratification tools help identify patients requiring specialist referral. In primary care, clinicians commonly use the FIB-4 score (and/or the NAFLD Fibrosis Score) to assess the likelihood of advanced fibrosis. Patients at higher risk or with indeterminate scores may then undergo further assessment with the Enhanced Liver Fibrosis (ELF) test, a blood test available through NHS laboratories that combines biomarkers to assess fibrosis risk (supported by NICE diagnostics guidance DG34), and/or transient elastography (FibroScan), which measures liver stiffness non-invasively. Those identified as having advanced fibrosis or cirrhosis are typically referred to hepatology services for specialist management. NICE recommends that adults with NAFLD have their risk of advanced fibrosis reassessed at intervals such as every three years, or more frequently if risk factors change.

Imaging studies provide direct visualisation of hepatic steatosis. Ultrasound scanning is the most commonly used first-line imaging modality in the NHS, offering a non-invasive, radiation-free method to detect fatty infiltration and assess liver size and texture. However, ultrasound may be normal in mild steatosis or in patients with high BMI, so diagnosis should integrate blood tests and risk stratification tools rather than relying on imaging alone. More advanced imaging techniques, such as MRI-based methods, offer high accuracy but are typically reserved for specific clinical scenarios due to cost and availability.

Liver biopsy, whilst considered the gold standard for assessing inflammation and fibrosis, is now reserved for cases where non-invasive tests are inconclusive or when alternative diagnoses require exclusion. The diagnostic pathway emphasises early identification, risk stratification using validated tools, and appropriate targeting of specialist resources to those at highest risk of disease progression, in line with guidance from NICE and professional societies such as the British Society of Gastroenterology and British Association for the Study of the Liver.

Frequently Asked Questions