The Liver: A Multi-Purpose Factory With Amazing Regenerative Powers

When I think about the liver, I’m often reminded of a comedy sketch from a Monty Python movie. In the sketch, organ donor nurses arrive at a patient’s home, requesting her liver before she is deceased. When the patient complains that she “hasn’t finished with it yet” the nurses launch into a whimsical song about how insignificant humans are compared to the vast size of the universe, and in the end, the patient reluctantly agrees to give them her organ, and the surgery commences in her living room. All completely silly, but the song is quite catchy.
   
But, I digress. The liver is a 3 pound, football-sized organ that sits just under the right rib cage. It is remarkably complex in its function, and does everything from detoxifying the blood (including breaking down medications and dumping them into the intestine where they are removed in the stool), producing blood clotting factors and various proteins, digesting fat and protein (the gall bladder stores soap-like chemicals produced by the liver), and storing glucose, vitamins and minerals, and helping to control metabolism. I think of it as a big, multi-functional factory that we can't live without.

What injures the liver?

1. Alcohol:  chronic, excessive alcohol consumption can cause inflammation of the liver cells which can lead to cirrhosis and eventually liver failure.
2. Obesity: being very overweight can cause fat to be stored in the liver which disrupts its function. "Fatty liver" can cause liver failure in severe cases.
3. Hepatitis Viruses: there are several viruses that attack the liver cells and can cause severe damage. Hepatitis B and C are the most dangerous, though great strides have been made in treating these viruses, such that hepatitis is now considered curable in most cases.
4. Medications: the liver is full of enzymes that break down toxins and medications, but some medications can irritate, inflame, or even cause liver failure in large quantities. Acetaminophen is probably the best known liver toxin in large doses.
5. Gall Stones: gall acts like soap, helping to break down fat and protein in the foods we eat. The extra soap (made by the liver) is stored in a sac called the gall bladder. Sometimes this soap gets a little dry and forms "stones" which can get stuck in the liver and cause pain and infections that can be life threatening. Interestingly, gall is very intensely colored (kind of neon green or yellow) and when it leaks into the blood stream, it can turn the skin yellow – which is what we call "jaundice" and is a sign of liver injury.
6. Liver Cancer: cancer that starts in the liver is fairly rare, but very dangerous. Because all the blood returning to the heart goes through the liver, it is a common collecting station for other cancers that metastasize from elsewhere. Cancer that has not spread too widely in the liver may still be surgically removed and cured. Because amazingly, the liver is capable of regenerating - and when one of its lobes is removed, we can still survive quite nicely.
7. Genetic Disorders: there are some genetic diseases that cause large amounts of substances to be stored in the liver (such as iron or copper) which can clog it up and enlarge it and harm its ability to function.
8. Autoimmune Disease: sometimes the immune system attacks liver cells, resulting in significant damage to the bile ducts and liver tissue.
9. Parasites: although we don't think much about parasites in the United States, in the rest of the world, over 35 million people suffer from liver fluke parasites (from eating undercooked or raw river fish) that crawl up into the bile ducts and can even cause cancer!

What happens when the liver fails?

Although the liver is a fairly resilient organ, due to the fact that it can actually grow back when it is injured (the only organ that can do this!) sometimes it can become injured beyond repair, and then it goes into full failure with these results:

1. Blood flow backs up: if the liver is very inflamed and swollen, the blood that usually travels through it very easily cannot get through. This causes a big back up, and under high pressures, the liquid portion of the blood leaks into the belly (called "ascites"), and veins in the neck, face, and belly can become swollen (called "varices" and "telangiectasias").
2. Gall spills into the bloodstream: causing yellow-looking skin or "jaundice."
3. The blood stops clotting: due to inability to produce clotting factors, the blood becomes very thin and prone to bleeding. In combination with the back-up I described above, you can see how bleeding is a serious risk in liver failure.
4. Toxins build up in the blood, causing mental status changes, nausea, confusion, and lethargy.

How can I keep my liver healthy?

1. Do not drink excessive alcohol.
2. Maintain a healthy weight.
3. Be careful to follow dosing instructions on drug facts labels, especially acetaminophen.
4. If you have gallstones, discuss your options with your doctor. If you have severe right-sided abdominal pain (especially after eating a fatty meal), get that checked out right away. Infected, trapped gallstones can be life threatening.
5. If you become jaundiced, see your doctor right away.
6. Practice safe sex - hepatitis C virus is very contagious through sexual contact and/or through contact with infected peoples' blood.
7. Get vaccinated against Hepatitis A and B before going to countries where they are common.
8. Don't share needles. Hepatitis C is very contagious.

The good news is that for those with end-stage liver failure, transplantation may be an option. Liver transplants are usually very successfully, though unfortunately there are about 15,000 people on the waiting list for one right now in the United States. I myself have chosen to be an organ donor, and I hope you'll consider it too. Because (heaven forbid) if we are in an accident, at least that way we can give the gift of life to others. I have no doubt that (unlike that comedy sketch) there will not be a man who climbs out of our refrigerator to sing us a song about giving up our livers before we're finished with them!

References
https://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0072577/
http://www.mayoclinic.org/diseases-conditions/liver-problems/basics/causes/con-20025300
http://www.liverfoundation.org/abouttheliver/info/transplant/

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The Bladder: Gender Differences & Problems Peeing

One of the funniest "vanity" license plates I've seen was owned by a urologist (doctor who specializes in bladder, prostate, and kidney issues). It read, "NOPCME." In other words, "No pee? See me!" I'll never forget that blue sports car (though in retrospect, it probably should have been yellow!)

Urinary issues (both difficulty getting urine out and keeping urine in) is one of the most common problems that we face, especially as we age. In fact, almost 40% of women report having an episode of urine leakage in the past year. So why do we have so much difficulty with our bladders?

The bladder is a very stretchy, muscular sac that sits in the bottom of the pelvis. The bladder muscles are stimulated to relax or contract by a complex of nerves that are controlled without our conscious knowledge. The bottom of the sac has a small sphincter (similar to the function of the anus) that relaxes and opens when we will it to do so.

The problem with this sphincter is that for women, it is not a complete circle. The nearby vagina takes up some of the space that the muscle could use, and so the sphincter is not as strong as it is for men. Women who have vaginal child birth may experience some further weakening of the bladder sphincter. For these reasons, women are more prone to bladder leakage.

Men have a unique anatomical difference that can cause problems with urination as well. The tube from the bladder to the exterior of the body happens to travel through a gland, called the prostate. When this gland is enlarged, it can narrow the passageway for the urine, causing a back up into the bladder and need to urinate small amounts frequently.

Since the bladder has a complicated nerve supply, there is a lot that can go wrong there as well. For a successful void, your bladder has to contract the outside muscle (like a shrinking balloon) while at the same time, relaxing the sphincter. This takes coordination from both the brain and spinal cord. If you have a brain or spinal cord injury, this process may get out of synch, resulting in a floppy bladder, or a lot of pressure in the bladder with a tightly closed sphincter – or anything in between.

There are gender differences in exit tube length – kidneys make the urine, then it travels to the bladder via two ureters, it is stored in the bladder, and then passes out the urethra (another tube). Women have relatively short urethras, and men have longer ones that pass through the prostate gland and all the way out of the penis to the exterior of the body.

This urethra length difference is important because bladder infections are ten times more common in women. It's a fairly short journey for bacteria to climb up into the bladder and multiply in the nice warm urine. Luckily, bladder infections can be treated quite easily with antibiotics, and women should contact their doctor at the earliest signs of burning and pain with frequent urination.

Finally, a few other anatomic differences between men and women can affect urination. Women who have had babies may experience some stretching of the ligaments that hold the uterus in place. Sometimes the uterus can slide downwards and obstruct the bladder exit, or in severe cases, even exit trough the vagina. Urologists or gynecologists can surgically repair such issues, and bladder slings are quite common.

Men, on the other hand, are prone to prostate cancer and sometimes undergo surgery to remove the gland altogether.  Sometimes they have difficulty controlling their urine after such procedures.

Bloody urine is concerning for possible bladder cancer, so if you see red blood in your urine, contact your doctor right away.

There are many medications that have side effects for the urinary tract – diuretics (or "water pills") intentionally increase the amount of urine produced in order to reduce blood pressure or blood volume. More urine means a need to void more frequently. Anti-depressants can cause a decrease in bladder contraction (resulting in a "floppy" bladder), and muscle relaxants may also relax bladder muscle. Of course, caffeine is a bladder stimulant, and sleeping pills may reduce your awareness of a full bladder, causing stretching while you sleep.

Tips to keep your bladder healthy:

1. Do not smoke. I know that sounds strange and perhaps unrelated, but smoking greatly increases the risk for bladder cancer.
2. Limit caffeine intake if you're experiencing frequency or incontinence.
3. Be aware that too much fluid intake (or diuretics) can make overactive bladders worse.
4. For men with enlarged prostates: Stop drinking fluids several hours before bedtime to reduce the need to get up frequently at night.
5. For women: Kegel exercises may strengthen the bladder sphincter. *
6. For women: Reduce urinary tract infection risk by urinating after sexual intercourse to flush bacteria from the urethra.**

The good news is that we have many fairly effective solutions for bladder problems. There are medications for "overactive" bladders, as well as bladder stimulant medications. There are surgical procedures to help with anatomical barriers, and of course, all kinds of over-the-counter incontinence pads that provide invisible protection from leakage.

If you have a chronic bladder problem that is not improving with input from your primary care provider, it's important to see a specialist to figure out what is triggering it so that the right treatment is prescribed. As you now know, the bladder (and the entire urinary system) is very complex, and the root cause of difficulty urinating (or frequent urination) could be anything from a brain or spinal cord problem, to an enlarged prostate, sphincter weakness, medication side-effect, or overly-sensitive bladder nerves. Specialists can look inside the bladder with a tiny camera, or perform "urodynamic testing" to see if bladder pressures and fluid capacity are normal.

If you or someone you know is having difficulty with urinating, just remember that urologist's license plate - NOPCME!

References

http://www.webmd.com/urinary-incontinence-oab/news/20050523/adult-incontinence-how-common-is-it
*http://www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/kegel-exercises/art-20045283
** http://www.mdedge.com/jfponline/article/60079/womens-health/does-postcoital-voiding-prevent-urinary-tract-infections-young

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The Pancreas: Don’t Mess With It?

In medical school I learned the first rule of surgery: "Eat when you can, sleep when you can, and don't mess with the pancreas."

It may seem funny that the pancreas, of all organs, is held in such high regard by surgeons. What would make it as notable to them as eating and sleeping? As it turns out, 95% of the cells in the pancreas manufacture enzymes that help to break down food (protein, fat, and carbohydrates), and these enzymes are so powerful that if they are released into the abdominal cavity, they can create massive damage to our own tissues. So a healthy respect for the pancreas is certainly in order, especially if you have a scalpel in your hand.

The pancreas is about 4 inches long and is located just behind the stomach. It contains a collecting system for enzymes that empty into the small intestine (along with bile from the gallbladder) when the presence of food is detected. This is how we turn tough food like steak into absorbable protein. The intestines have special protective coatings, including a mucous barrier, that prevent the pancreatic enzymes from harming them.

Most people associate the pancreas with insulin, its number one hormone product. Insulin is produced by the other 5% of cells inside the organ. Insulin triggers the body to remove sugar from the blood and use or store it for energy. Without insulin, sugar (contained in the carbohydrate-rich food we eat) remains in the blood, causing it to be sticky and thick. High levels of blood sugar (over time) can cause damage to small blood vessels that supply our eyes, toes, kidneys, and nerves. This is why people with diabetes (who either have too little insulin, or make no insulin) can develop eye damage, foot ulcers, nerve pain, and kidney failure over time. Of note, the pancreas also makes the hormonal antidote to insulin, called glucagon, which triggers the body to release sugar into the bloodstream when levels are low.

What can go wrong with the pancreas?

1. Pancreatitis – inflammation of the pancreas occurs when its digestive enzymes build up to high levels and begin to irritate its own tissue. Pancreatitis can be very painful, and is diagnosed with lab tests that check for high levels of pancreatic enzymes in the blood stream.
2. Pancreatic cysts – because the pancreas is very glandular and is constantly producing enzymes and hormones, it can develop fluid filled sacs, or cysts, that can cause structural problems.
3. Pancreatic Cancer – though rare, cancer of the pancreas is very dangerous. There are several sub-types of cancer, depending on which cells are affected. More information about pancreatic cancer is available here: http://www.mayoclinic.org/diseases-conditions/pancreatic-cancer/home/ovc-20268502
4. Insulin Insufficiency – some people do not produce enough insulin to meet their body's needs. Being overweight or obese can cause resistance to insulin and a higher insulin requirement. If the pancreas doesn't keep up with the needs, "Type 2" diabetes develops.
5. Autoimmune destruction of insulin-producing cells – in some cases, our body's immune system mistakes insulin cells for foreign invaders and attacks them. When these cells are destroyed, the body produces no more insulin, and "Type 1" diabetes results. People with type 1 diabetes cannot survive without insulin injections to replace their lost insulin production.

How to keep your pancreas healthy:

1. Avoid excessive use of alcohol – chronic alcohol consumption is the number one cause of pancreatitis.
2. Maintain a healthy weight – gallstones can hurt the pancreas by plugging up the common passageway that they, along with pancreatic enzymes, flow through to get to the intestine. Gallstones are more likely to form in people who are overweight or obese, or eat high fat diets.
3. Don't smoke – cigarette smoking increases the risk of pancreatitis and pancreatic cancer.
4. Limit your consumption of sugary food and drinks and high fat and processed foods. They can increase the fat content of your blood, which can lead to pancreatitis.

The bottom line for pancreas health: eat healthfully (such as the Mediterranean diet), maintain a healthy weight, exercise regularly, and avoid drinking and smoking. I suppose you could say that "clean living" is the best way to avoid "messing with the pancreas."

References
http://columbiasurgery.org/pancreas
http://www.mayoclinic.org/diseases-conditions/pancreatic-cancer/home/ovc-20268502
https://authoritynutrition.com/mediterranean-diet-meal-plan/

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