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Year : 2023  |  Volume : 22  |  Issue : 1  |  Page : 124-127  

Hepatocellular carcinoma presenting as right shoulder pain

Department of Internal Medicine, University of Health and Allied Sciences, PMB 31, Ho, Ghana

Date of Submission17-Dec-2021
Date of Decision15-Jan-2022
Date of Acceptance29-Jan-2022
Date of Web Publication24-Jan-2023

Correspondence Address:
Senyo Tagboto
University of Health and Allied Sciences, PMB 31, Ho
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aam.aam_257_21

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We report an uncommon presentation of liver cancer in a 33-year-old woman who presented with persistent right shoulder pain with a normal physical examination of her shoulder and normal X-rays. An abdominal ultrasound scan and a computed tomography scan subsequently revealed a large liver cancer in this patient who was subsequently found to be hepatitis B positive. Extrinsic causes of shoulder pain should be considered when shoulder movement is normal and does not alter the character of the pain. Subdiaphragmatic liver lesions should be considered in the differential diagnosis of right shoulder pain. In any geographical area with a high incidence of hepatitis B infection, hepatocellular carcinoma should be included in the differential diagnosis of shoulder pain if a clear local cause is not identified.

   Abstract in French 

Nous rapportons une présentation peu fréquente du cancer du foie chez une femme de 33 ans qui présentait une douleur persistante à l'épaule droite avec une douleur normale examen physique de son épaule et radiographies normales. Une échographie abdominale et une tomodensitométrie ont par la suite révélé un gros cancer du foie chez ce patient qui s'est avéré par la suite positif à l'hépatite B. Les causes extrinsèques de la douleur à l'épaule doivent être prises en compte lorsque le mouvement de l'épaule est normal et ne modifie pas le caractère de la douleur. Des lésions hépatiques sous-diaphragmatiques doivent être envisagées dans le diagnostic différentiel de la douleur à l'épaule droite. Dans toute zone géographique où l'incidence de l'hépatite B est élevée, carcinome hépatocellulaire devrait être inclus dans le diagnostic différentiel de la douleur à l'épaule si une cause locale claire n'est pas identifiée.
Mots-clés: Hépatite B, cancer du foie, douleur à l'épaule

Keywords: Hepatitis B, liver cancer, shoulder pain

How to cite this article:
Tagboto S. Hepatocellular carcinoma presenting as right shoulder pain. Ann Afr Med 2023;22:124-7

How to cite this URL:
Tagboto S. Hepatocellular carcinoma presenting as right shoulder pain. Ann Afr Med [serial online] 2023 [cited 2023 Jan 29];22:124-7. Available from:

   Introduction Top

Shoulder pain is one of the most common musculoskeletal conditions encountered in primary care and specialty orthopedic clinic setting.[1] Musculoskeletal complaints are common in certain professions including in the nursing profession.[2]

This pain may be due either to intrinsic disorders of the shoulder or referred pain [Table 1].
Table 1: Extrinsic causes of shoulder pain

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The former includes injuries and acute or chronic degeneration or inflammation of the shoulder joint, tendons, surrounding ligaments, or periarticular structures and includes osteoarthritis, overuse injury, rotator cuff tendinitis or tears, biceps tendinitis, subacromial bursitis or inflammatory bursitis, adhesive capsulitis, acromioclavicular joint syndrome, glenohumeral dislocation, myofascial pain, or local fractures. In addition, shoulder pain may be cause by local malignancy, local infection, or may be part of inflammatory disorders such as rheumatoid arthritis or polymyalgia rheumatica or may occur following laparoscopic surgery.[3],[4]

The main reason for presenting this case is to highlight the fact that there are a number of potentially serious extrinsic causes which should be considered in patients with no history of trauma, stiffness, lack of flexibility, weakness, loss of function, or joint instability and in whom the pain is not provoked by specific movements.[5],[6],[7],[8]

Hepatocellular carcinoma (HCC) has a wide spectrum of clinical presentations from asymptomatic disease to life-threatening illness. Most patients have established the risk factors for chronic liver disease including hepatitis B or C virus infection, heavy alcohol drinking, and nonalcoholic fatty liver disease. Furthermore, the majority of cases occur in association with chronic liver disease, as such, symptoms and physical findings are often due to underlying cirrhosis.[9] Cirrhotic patients tend to have less tolerance for malignant infiltration within the liver and frequently present with nonspecific signs and symptoms of hepatic decompensation such as jaundice, hepatic encephalopathy, and anasarca.[10] Ascites, variceal bleeding, or other findings consistent with portal hypertension may indicate malignant invasion of HCC into portal structures. Patients with advanced lesions may present with mild-to-moderate upper abdominal pain, weight loss, early satiety, or a palpable mass in the upper abdomen.[10]

Noncirrhotic patients, as is commonly seen in Sub-Saharan Africa present somewhat differently. Their tumors are often able to grow considerably and as such, symptoms are often related to long-standing malignancy including malaise, anorexia, wasting, right upper quadrant abdominal pain, and distension. Physical examination may reveal an abdominal mass or hepatomegaly with hard and irregular borders that may demonstrate a vascular bruit.[10] Painless obstructive jaundice can indicate tumor encroachment onto adjacent extrahepatic biliary structures.[11] A rare catastrophic complication of HCC is tumor rupture which occurs when a large vascular tumor on the periphery of the liver outgrows its blood supply. These patients present with sudden severe abdominal pain, peritoneal irritation, and hypotension.[12]

Some patients may develop a paraneoplastic syndrome that can manifest as hypoglycemia, erythrocytosis, hypercalcemia, severe diarrhea (thought to be due to the increased production of intestinal secretory substances, such as gastrin and vasoactive intestinal peptide), and feminization syndrome.[13],[14] HCC can metastasize to any organ system via hematogenous or lymphatic routes, and most commonly spreads to the bone, lung, and abdominal viscera and may present with bone pain or symptoms related to metastatic disease.[15]

HCC can usually be diagnosed noninvasively and according to the current guidelines, a single contrast-enhanced imaging study computed tomography (CT) or magnetic resonance imaging (MRI) showing typical hallmarks of HCC in people with cirrhosis is valid to diagnose HCC.[16]

The diagnosis may be made with contrast-enhanced CT, MRI, or ultrasound (US).[17] The serum tumor marker alfa-fetoprotein is also helpful in making a diagnosis.[18] A liver biopsy may be considered in patients with liver lesions without risk factors, where imaging modalities do not show typical hallmarks, where metastatic disease is being considered which could potentially change management, where a cholangiocarcinoma is suspected or when histologic grading or molecular characterization of the tumor is desired.[16],[19]

HCC is the fourth leading cause of cancer-related deaths worldwide, and the overall prognosis of HCC remains dismal, except for the subset of patients who are diagnosed at early stage and receive potentially curative therapies, such as surgical resection and liver transplantation.[9] High-risk patients are therefore candidates for surveillance, typically with US although the diagnosis can be made with contrast-enhanced CT, MRI, or US. The serum tumor marker alfa-fetoprotein is also important in surveillance which should be considered in most patients with cirrhosis and some with chronic hepatitis B virus infection.

   Case Report Top

A 33-year-old nurse initially presented to the orthopaedic surgical department in August 2021 with persistent right shoulder pain. She had no history of trauma, and did not complain of stiffness, lack of flexibility, or weakness. In addition, she did not report loss of function or joint instability. Furthermore, the pain was not provoked by specific movements and an X-ray of her shoulder looked unremarkable. A diagnosis of musculoskeletal pain was made by her clinicians, and she was given a prescription for analgesia.

Two months later, however, due to persistent pain, she visited the internal medicine department with her fiancé. Their principal concern at the time was that she was planning to get married in a month's time and wanted this pain sorted out before her pending wedding and that she additionally wanted a medical checkup.

On further questioning, she reported weight loss of about 2 kg and tiredness which she put down to the stress of preparing for her wedding. On systematic inquiry, she additionally complained of epigastric discomfort which she had for a year. She had been treated with triple therapy for a Helicobacter pylori infection and had additionally been put on proton-pump inhibitors intermittently.

She admitted to a reduced appetite but there was no history of altered bowel habits, jaundice, or melena and her stool had a normal brown color. She had no cardiorespiratory symptoms.

She is a nonsmoker and has been a lifelong nondrinker. Both parents were alive and well. Her mother was 60-year-old and her father 67. She had no recollection to receiving blood or blood products in the past and no tattoos or parenteral injections. Her younger sister had died of a liver cancer a year previously.

On examination, she looked well but was drowsy following a dose of morphine. She had taken for the shoulder pain that morning. She was not pale or jaundiced with no evidence of clubbing or lymphadenopathy. Respiratory and cardiovascular examinations were normal. On the examination of her abdomen, her liver was firm and palpable 3 cm below her costal margins. There were no other masses palpable, and a neurological examination was normal.

Her liver function tests showed a mildly elevated alkaline phosphatase, aspartate transaminase (AST), and gamma-glutamyl transferase levels only (total bilirubin 7 μmol/l, conjugated bilirubin 3 μmol/l, AST 132 IU/ml [0–32], alanine transaminase 27 IU/ml, alkaline phosphatase 162 IU/ml [35–105], gamma-glutamyl transferase 151 IU/ml [<38], and total protein 82 g/l serum albumin 33 g/l). A full blood count demonstrated a normocytic anemia (HB 8.4 g/dl). Her renal function and calcium levels were all within normal limits.

Further, testing showed that her hepatitis B surface antigen was positive, but a hepatitis C antibody screen was negative. Her hepatitis B viral DNA was reported as 12,900 IU/ml and alpha-fetoprotein levels were elevated at 10,108 IU/ml.

An abdominopelvic ultrasound and a CT scan of her abdomen demonstrated a large heterogenous solitary hepatic mass involving most of the right lobe with areas of necrosis. The mass had a craniocaudal length of 15.2 cm, anteroposterior length of 12 cm, and a transverse diameter of 10.9 cm. There was a mass effect on the right portal vein with associated thrombosis, and a small right-sided pleural effusion.

The patient was then referred to the hepatobiliary surgical and oncology teams at a tertiary referral center who after a multidisciplinary meeting, felt that the lesion was not amenable to surgery and that management would be palliative. The team felt that the imaging was diagnostic and did not carry out a liver biopsy.

She then presented 3 weeks later complaining of shortness of breath and pain in her right lower chest. A chest X-ray showed a large pleural effusion. A chest tube was inserted and pleural fluid sent for cytology which was reported as a hypercellular smear composed of a small cluster of epithelial cells with pleomorphism, prominent nucleoli, hyperchromasia, multiple nucleoli, increased nuclear/cytoplasmic ratio, and atypical naked nuclei with a hemorrhagic and inflammatory background comprised mostly of neutrophils. There were also atypical spindle cells, suggestive of a spindle cell HCC.

   Discussion Top

We have presented the case of a 33-year-old patient presenting with persistent right shoulder pain.

The reason for this presentation is to demonstrate the possibility of an atypical presentation of HCC. Second, to emphasize on the importance of a thorough history and physical examination to establish a diagnosis.

In addition, this presentation is to highlight the importance of looking for extrinsic causes when the physical examination of the shoulder is normal with no preceding trauma and no history of stiffness, stiffness, lack of flexibility, weakness, loss of function, or joint instability and in whom the pain is not provoked by specific movements.

In Ghana, the prevalence of hepatitis B infection has been quoted as being 8% with reports of up to 12.3% in some areas.[20] The prevalence of hepatitis C infection in Sub-Saharan Africa is approximately 5.3%.[21] Furthermore, 40% of patients with cirrhosis of the liver in Ghana were found to be hepatitis B virus carriers.[22]

This case underlines the importance of considering hepatobiliary disease in patients from areas with a high prevalence of hepatitis B or C infection.

Learning points

  • Shoulder pain is a common medical condition and may be due to intrinsic shoulder disease or a number of serious extrinsic conditions
  • In patients known to be carriers of hepatitis B infection or in areas with a high prevalence of hepatitis B infection, HCC should be considered in the differential diagnosis of right shoulder pain
  • A normal physical examination, the lack of a history of trauma, absence of stiffness, weakness, and the absence of pain provoked by specific movements may suggest an extrinsic cause of the shoulder pain
  • A careful and detailed history and physical examination should be undertaken in all patients with shoulder pain.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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Halliday M, Ingersoll J, Alex J. Atraumatic splenic rupture after weight lifting in a patient presenting with left shoulder pain. Mil Med 2020;185:e2918-2200.  Back to cited text no. 6
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Kanwal F, Singal AG. Surveillance for hepatocellular carcinoma: Current best practice and future direction. Gastroenterology 2019;157:54-64.  Back to cited text no. 9
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Murata K, Shiraki K, Kawakita T, Yamamoto N, Okano H, Sakai T, et al. Hepatocellular carcinoma presenting with obstructive jaundice: A clinicopathological study of eight cases. Hepatogastroenterology 2003;50:2057-60.  Back to cited text no. 11
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Bruix J, Castells A, Calvet X, Feu F, Bru C, Solé M, et al. Diarrhea as a presenting symptom of hepatocellular carcinoma. Dig Dis Sci 1990;35:681-5.  Back to cited text no. 13
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Kim TH, Kim SY, Tang A, Lee JM. Comparison of international guidelines for noninvasive diagnosis of hepatocellular carcinoma: 2018 update. Clin Mol Hepatol 2019;25:245-63.  Back to cited text no. 17
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