Symptoms of Liver Cancer

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The signs and symptoms of liver cancer are most often the result of liver damage and may include yellowing of the skin (jaundice), right-sided abdominal or shoulder blade pain, or a lump in the right upper abdomen. However, many of the warning signs are non-specific, such as weight loss and fatigue. Sometimes the complications of liver cancer, such as a bile duct obstruction, anemia, or bleeding are the first symptoms. Since there's no screening test for liver cancer, having an awareness of the potential signs and symptoms is the only way to find the disease early. 

It's important to briefly differentiate primary liver cancer—that which originates in the liver—from liver metastases, which is the spread of cancer (breast or lung, for example) from another region of the body to the liver. Liver cancer is usually a single large tumor, while metastases (spread) are usually small and multiple.

Primary liver cancer usually causes symptoms relatively early, whereas liver metastases (which are much more common) may occupy a significant part of the liver before they are detected.

Symptoms are similar for hepatocellular carcinoma (liver cancer) and cholangiocarcinoma (bile duct cancer), but bile duct cancers tend to cause symptoms of obstruction (such as jaundice) earlier than many liver cancers.

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Frequent Symptoms

Like many types of cancer, liver cancer usually has few symptoms or signs in the early stages of the disease. As the disease progresses, its symptoms begin to appear, prompting one to seek medical attention. Due to this delayed onset of symptoms, liver cancer is often diagnosed in an advanced stage (unless the tumor originates near a bile duct and causes an obstruction early).

Symptoms that may occur include:

An Abdominal Mass or Lump 

You may feel a very hard lump or swelling in the region just below your rib cage on your right side. Often, this mass is painless, and if you have pain, you may feel more discomfort in the areas surrounding the mass. 

Sometimes liver cancer causes enlargement of the spleen as well, which can result in pain or a mass felt in the left upper abdomen.

Right-Sided Abdominal Pain 

Pain, discomfort, or aching on the right side of the abdomen just under the ribs may occur due to the pressure of a liver tumor on other structures or nerves in this region. Take in a deep breath and press lightly upward under your rib cage on the right side—this is roughly where your liver lies. If you have an enlarged liver (there are many causes), the edge of your liver may be felt lower in your abdomen.

Right Shoulder Blade Pain 

Shoulder blade pain can be a sneaky symptom, as the condition it is alerting you to may not be anywhere near the shoulder blade (due to the way nerves travel in our bodies).

This is the case with liver cancer. The tumor (or spread from the tumor) can irritate nerves that tell your brain the pain is coming from your shoulder blade when it's actually coming from the liver. This pain is typically felt in the right shoulder, though it may occur on either side. The pain may also extend into your back. 

If you experience this, especially if you haven't engaged in any recent physical activity that might explain it, see your physician. 

Jaundice 

Jaundice refers to a condition in which the skin, as well as the white part of the eyes, appears yellow. It is caused by the build-up of bile salts in the skin.

It is more easily detected in natural light, such as being outside, than in indoor light. In addition to yellowing of the skin, some people notice that their bowel movements appear pale and whitish instead of brown. At the same time, urine may appear darker than normal, even without dehydration.

Itching

The build-up of bile salts in the skin, which results in jaundice, can also cause itching. We don't often think of itching as a serious symptom, but the itching associated with liver dysfunction can be very intense.

Bloat and Shortness of Breath

Fluid build-up in the abdomen referred to as ascites can indicate liver cancer. It may feel like bloating at first; some people note that their clothes don't fit properly in the waistline or their belt size changes even though they haven't gained weight. In time, fluid build-up in the abdomen can push upward on the lungs causing shortness of breath.

Unintentional Weight Loss or Gain

Unintentional weight loss might be welcomed by some, but when it not related to a change in diet or exercise, it always deserves a visit to a doctor. Unexplained weight loss is defined as the loss of 5 percent of body weight or more over a six- to 12-month period without trying. An example would be a 200-pound man losing 10 pounds over a period of six months without a change in habits.

Unintentional weight loss was found to be related to an underlying cancer in a third of people observed in a 2017 review of studies, including liver cancer. There are other serious causes as well, so it's important to see a doctor as soon you recognize such a change.

Rapid and unexpected weight gain is also a possible sign of liver cancer. This usually occurs due to the rapid build-up of fluid in the abdomen (ascites).

Loss of Appetite 

A loss of appetite may occur with many disorders, but can be quite profound with liver problems. This may be accompanied by a sense of becoming full very rapidly, even when eating only small meals. As these symptoms could be warning signs of not only liver cancer but other cancers, a visit to a physician is warranted.

Nausea and Vomiting

There are several reasons why liver cancer can lead to nausea and vomiting, and this is a common symptom at all stages of the disease. There are a vast number of causes for nausea and vomiting, but when it occurs frequently, or if it is worsening, talk to your doctor.

Fatigue and/or Weakness

It seems everyone is tired these days, but cancer-related fatigue often takes things to a new level. Cancer fatigue is different from ordinary tiredness, and it is not the kind of fatigue that improves with a good night of sleep. Sometimes this symptom is easier to see if you look back at a period of six to 12 months and gauge your energy today against what it was at that time. 

Fever

A low-grade, but persistent fever, something physicians refer to as a "fever of unknown origin" or FUO, is a fairly common symptom of liver cancer. An FUO is defined as a temperature greater than 101 degrees that last for three or more weeks and that cannot be tied to an obvious cause after three or more doctor's visits (or three days in the hospital). There are several other potential causes of a persistent fever, but having one is a good reason to see your physician.

General Feeling of Being Unwell

It's hard to describe intuition as a symptom, but studies tell us—often in retrospect—that people often sense when something is "off" in their body. If you have a general sense that you are not well, see your doctor. Sometimes, symptoms can be hard to define in terms like those listed above. Our bodies often do a good job of "telling" us when something is amiss if we only take the time to listen.

Rare Symptoms

Some liver cancers secrete hormones that can cause additional symptoms. These may include low blood sugar (hypoglycemia) that can result in lightheadedness and fainting, especially in people who haven't eaten for a while; breast enlargement (gynecomastia); testicular atrophy; and a high red blood cell count.

Complications

Liver cancer can result in a number of complications. They may result from the pressure of a tumor on the bile duct or other organs, hormones produced by the cancer cells, liver dysfunction that results in the build-up of toxins in the body, or other mechanisms.

Some potential complications include:

Anemia

Anemia, a low red blood cell count, is a very common complication of liver cancer and may occur due to a few mechanisms, including a lack of clotting factors in the blood leading to bleeding. Anemia can be insidious at first, and it frequently causes symptoms such as fatigue, shortness of breath, a rapid heart rate, pale skin, and lightheadedness. Since liver cancer can sometimes result in erythrocytosis (increased red blood cell production) as well, these effects sometimes cancel each other out.

Bile Duct Obstruction

Bile is made in the liver. Several ducts ensure that it gets transported to the small intestine, either via the gallbladder or directly. Liver tumors or bile duct tumors can grow within a duct or exert pressure near one, resulting in bile duct obstruction.

When a duct is obstructed for either reason, it usually results in the rapid onset of severe and constant pain in the right upper abdomen, nausea, vomiting, jaundice, and itching.

Bleeding

The liver is responsible for making proteins (clotting factors) that help your blood clot. When a large percentage of your liver has been overtaken by cancer, these factors are no longer produced in sufficient numbers. The result is that bleeding may occur (even with a normal number of platelets) and anemia may ensue. The first sign is often bleeding when you brush your teeth or frequent nosebleeds. More serious bleeding, such as internal hemorrhage, may occur when the cancer is advanced.

Portal Hypertension

Liver cancer (and other liver diseases) can lead to bleeding from the digestive tract in another way as well. A tumor within the liver can make it difficult for blood to flow through the small veins in the organ that lead to the large portal vein. The resulting pressure on the vein (portal hypertension) causes increased pressure in blood vessels upstream, such as those in the esophagus.

These veins are weaker than the larger portal vein and can develop into varicose veins, much like you see on people's legs, or on the abdomen at times with liver disease. When these varicosities rupture, it can result in massive bleeding into the esophagus (esophageal variceal bleeding, which can be life-threatening if not treated rapidly. Bleeding may occur in the stomach and intestines as well due to the same mechanism.

High Blood Calcium (Hypercalcemia)

Liver cancer may result in a high calcium level in the blood (hypercalcemia of malignancy) through a few different mechanisms. This may cause nausea and vomiting, extreme muscle weakness, and confusion, which can progress to coma and even death if not treated.

Hepatorenal Syndrome

Hepatorenal syndrome is a condition in which liver disease leads to kidney disease due to changes in blood vessels and reduced blood flow to the kidneys. Hepatorenal syndrome is very common with liver cancer and other forms of liver disease, and it's estimated that 40 percent of people who have cirrhosis will develop the syndrome within five years. Unfortunately, it is usually irreversible in these individuals unless liver transplantation is performed.

Hepatic Encephalopathy

Hepatic encephalopathy can be a frightening complication of liver cancer but is actually a reversible cause of symptoms that can look like Alzheimer's disease.

When the liver is unable to remove toxins, they travel to the brain. This can result in memory loss, disorientation, personality changes, and severe confusion. Symptoms may begin mildly with difficulty doing math-centered tasks, like balancing a checkbook. Other symptoms may include breath that has a sweet odor and flapping of the arms when they are held out straight in front of a person. There are ways to treat the encephalopathy, but the prognosis usually depends on the extent of the tumor.

When to See a Doctor

If you note any of the signs and symptoms above or any you can't explain, see your doctor. While many can indicate harmless conditions, if liver cancer is present, the prognosis is generally better the earlier the disease is diagnosed. People who have no risk factors for liver cancer can and do develop the disease at times—something worth keeping in mind if you're unsure about speaking with your physician.

If you do have risk factors for liver cancer, such as cirrhosis, your situation is a bit more challenging. You may already be experiencing similar symptoms as a result of an existing health issue. In this case, the key point is to watch for a change in your symptoms.

One study found that symptoms that alerted physicians to the presence of liver cancer in people with chronic liver disease included right upper quadrant pain, enlargement of the liver (cirrhosis usually causes it to shrink), more fatigue, a change in mood, worsening of portal hypertension, hemorrhoids, bleeding, and diabetes that had become difficult to control. If you notice any of these symptoms, contact your doctor right away instead of waiting for your next scheduled appointment.

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