Can dense adhesions around the liver, noted during laparoscopic surgery for endometriosis, cause intermittent and chronic right upper quadrant pain and elevated liver enzymes?

Hepatic Adhesions from Endometriosis Can Cause Right Upper Quadrant Pain

Yes, dense adhesions around the liver noted during laparoscopic surgery for endometriosis can cause intermittent and chronic right upper quadrant pain and elevated liver enzymes. 1, 2

Pathophysiology of Hepatic Endometriosis and Adhesions

• Endometriosis can cause anatomic distortion through invasive growth and adhesions, which may affect organs beyond the pelvis, including the liver 1
• Dense adhesions can restrict normal organ movement, causing pain through peritoneal surfaces innervated by peripheral spinal nerves 1
• The depth of endometriotic lesions correlates with severity of pain, rather than the type of lesions seen during laparoscopy 1
• Endometriosis affecting extrapelvic sites like the liver is less common but can cause significant symptoms when present 2

Diagnostic Considerations

• Laparoscopy with histologic confirmation remains the gold standard for diagnosing endometriosis, including at extrapelvic sites 2
• MRI is an excellent imaging modality for detecting signs of adhesions, including low-signal intensity bands and obliteration of organ interfaces 2
• Adhesions can be suspected on imaging when there is obliteration of organ interfaces or fixed positioning of organs 2
• Elevated liver enzymes may occur due to inflammatory processes or mechanical obstruction from adhesions around the liver 3

Management Options

Medical Management

• First-line treatment includes NSAIDs for pain management 4
• Hormonal therapies such as oral contraceptives, progestins, or GnRH agonists can help reduce endometriotic lesions and associated inflammation 4
• GnRH agonists for at least three months provide significant pain relief and may help reduce inflammation around hepatic adhesions 4
• When using GnRH agonists long-term, add-back therapy should be implemented to reduce bone mineral loss 4

Surgical Management

• Surgical treatment aims to remove all visible areas of endometriosis and restore anatomy by division of adhesions 5
• Laparoscopic adhesiolysis (removal of adhesions) can be effective for pain relief in cases of dense adhesions 6, 5
• Advanced laparoscopic techniques including hydrodissection and CO2 super pulsed laser can aid in removal of adherent endometriotic implants without damage to underlying structures 6
• Surgical outcomes are generally better for advanced disease with adhesions, with improvement in pain reported in up to 67% of cases 7

Prognosis and Follow-up

• Up to 44% of women experience symptom recurrence within one year after surgery for endometriosis 4
• Prior surgery for endometriosis, extensive adhesions, and use of ovarian stimulation drugs are negative prognostic factors for pain recurrence 8
• Pregnancy has shown a significant protective effect on pain and disease recurrence 8
• Regular follow-up every 3 months is recommended to monitor for recurrence of symptoms 8

Important Considerations

• Pain from hepatic adhesions may present differently from typical endometriosis pain, with right upper quadrant location rather than pelvic focus 3
• Elevated liver enzymes should prompt investigation for other causes, but may be related to hepatic involvement of endometriosis 3
• The diagnosis of hepatic endometriosis or adhesions is often delayed due to its atypical presentation 3
• No medical therapy has been proven to completely eradicate endometriotic lesions, including those causing hepatic adhesions 1