Sorry, we tried to cram in a lot of information for you guys in here. Each of these things are like, you know, 45 minutes to an hour of talks in themselves. So we're dealing with the pathological conditions in the liver and the gallbladder and the pancreas. The first one we talk about is cirrhosis. Cirrhosis is when the liver tissue is replaced by scar tissue, essentially, and the scarring is usually from chronic inflammation. Generally, it is an irreversible condition, but in some specific insults, you could have some reversible liver disease. So the liver, essentially, all the things that we talked about in terms of, you know, what it does, it stops doing it, or it doesn't do it effectively, and therefore, the result in, you know, all the other consequences. What can cause the liver disease? You know, right now, the number one is, and rapidly growing, is the non-alcoholic fatty liver disease, which essentially is fat in the liver leading to more inflammation and scar tissue. So you see that in obese individuals, diabetics, metabolic syndrome, those who have high blood pressure, heart problems, and so on. Those are the ones that tend to have this type of condition. Alcohol-associated liver disease, we talked about alcohol affecting the liver. Certain infections, like hepatitis C and B. Hepatitis C used to be the number one cause, and it's come down because we have now treatment for hepatitis C, where we are able to, you know, eradicate hepatitis C infection, same with hepatitis B, or at least keep it under check with hepatitis B. And there are several other conditions, which can either be autoimmune-related or excessive ion deposition, excessive copper deposition, some enzyme deficiencies, and so on, which can lead to liver problems. So there are a lot of symptoms these folks can present with, and they will have, you know, generalized fatigue. There could be complications of certain things that we talked about, like viruses and so on. And there are, again, various blood tests, ultrasounds, biopsies that you could use to confirm the diagnosis that somebody either has advanced liver disease or inflammation in the liver, leading up to cirrhosis as well. The gold standard is really to get a biopsy, but in most cases, these days, we are able to kind of, you know, predict who has cirrhosis based on noninvasive testing. So this is one of the things we talked about in terms of the treatment, doing an endoscopy for these varices. Varices just like on the coughs, you know, how you see these, you know, veins popping up and becoming all tortuous, same thing is happening around the esophagus and the stomach where the veins have become really enlarged, very tortuous, you know, very plump. They come up to the surface of the lining of the esophagus, and sometimes they pop, and that results in torrential bleeding for these folks. So this is how, you know, gastric varices look. These are how the esophageal varices look, and you band them to reduce the risk of bleeding. There are also medical therapies available. And you can also, remember we talked about the portal circulation and the systemic circulation in the liver. So you can essentially bridge that portal and systemic circulation using a stent, and that's called a TIPS procedure. So it's done by our radiology colleagues, where they'll go through the neck, try to identify the hepatic vein, the one connecting the systemic circulation, and put a stent between the hepatic vein and the portal vein. And that's how they decompress all the engorgement of the portal circulation. Ascites, all these are manifestations of what we call portal hypertension. So because the liver is now scarred down, it's not allowing the blood to flow through easily between the portal and the systemic circulation. So all that backflow results in engorgement of veins in the portal circulation. So portal circulation is circulation, you know, connected to the intestines. So that's how you get ascites and fluid leaking out from that into your belly, resulting in ascites. And the treatment for ascites is to follow a low-sodium diet to try to keep the fluid not to leak from the blood vessels into the space outside the blood vessels using diuretics, which again changes these electrolyte balances, and again, the TIPS, which is the treatment for portal hypertension in these folks. If you have fluid inside your belly, you're at risk of getting infection, and that is called SBP. Without any of us trying to introduce anything into it, the bacteria from the intestines can translocate and move into that fluid, resulting in infection. So again, a lot of information on this slide, but bottom line is that because the toxins are not being neutralized by the liver, you get the toxins entering the systemic circulation, resulting in the brain getting affected, the nervous system getting affected, and patients can have, you know, subtle changes in their judgment to a fluoride, you know, becoming comatose. So it could vary, you know, in the spectrum of hepatic encephalopathy. The treatment for those folks is to make sure they don't have any infection, and also lactulose and rifaximin, a couple of medications to flush out the toxins from the intestines and thereby reduce their chances of getting encephalopathy. One test that we use in the right clinical setting is the ammonia level in their blood. So by doing that, we can check if they have encephalopathy. We can confirm the diagnosis of encephalopathy in the right setting. Sometimes ammonia could be high in other settings as well, but in the right clinical setting, it's useful. Anywhere you have chronic inflammation, there is a risk of getting cancer down the road. So because there is chronic inflammation in the liver, that can lead to a cancer, and it's called hepatocellular carcinoma or liver cancer. And it's the fifth most common cancer in the United States, but also a lot of people die from it because the treatment is really to do a liver transplant in these folks. If it's really small, sometimes you can do surgery, but not many folks, you know, fall into that category. Many of them have, you know, really bad liver disease that they cannot undergo surgery, or there are too many of these that they require a liver transplant. If they have hepatitis B infection, it increases the risk. If they have cirrhosis from any cause, it increases the risk. The management we talked about is, you know, either surgery or doing a liver transplant. You can kind of, you know, keep tabs on these by doing ablation and embolization of these tumors. So those are local therapies sometimes you could use as well. In folks who have, you know, really advanced cancer, they cannot get to transplant. They don't qualify for transplant if they have advanced cancer. And in those cases, all you have is really chemotherapy, which essentially, you know, doesn't keep them alive for very long. Liver transplant, the indications include, you know, what we just talked about. In addition to those two, cirrhosis and the cancer, some folks develop acute failure. The liver just fails suddenly. And in those cases, they don't develop all the other signs of what the chronic liver failure, the cirrhosis develop. But their liver is completely shut down. They go into encephalopathy. They have bleeding. They have kidneys shutting down. And there, they also need liver transplant more urgently. In majority of the folks, the way we do the transplant is from a deceased patient. We take that liver and put it in our patient. But in some cases, you can also do a living donor transplant, which means in somebody who's alive, you take a portion of the liver and give it to your patient. And that actually can, you know, that part is enough for them to function normally. So usually family members or sometimes you have just, you know, matched people who can donate liver, even if you're not related to the patient. So only a few centers across the country who do living donor transplants. And you can see the numbers are different. Once you do a liver transplant, they survive really well. But look at the number of people who are waiting just in the U.S. to get a liver transplant. So it's a huge, huge number of people waiting to get transplanted. Other liver conditions include alcohol-related inflammation, which is, again, acute inflammation. Folks who have, you know, binged with alcohol, and they suddenly develop inflammation and jaundice. And, you know, this is kind of another definition that we use to say it is enough consumption of alcohol. And there is treatment to use steroids in those cases to help with reducing that inflammation and getting the liver to function back again, close to being normal, and prevent them from going into liver failure. Sometimes even though they are actively drinking alcoholics, they can still get a transplant as long as there is an adequate, you know, social support and we get some sort of commitment by, you know, psychiatry evaluations and social worker evaluations that they are eligible to get a transplant. This is the bigger problem in our country right now, which is the non-alcoholic fatty liver disease, you know, coinciding with the obesity pandemic that we are living in. So around 32 percent of the world's population has this. It's the most common liver disease in Western countries. And I think there's a couple of reps who are here today, you know, from representing your companies that are heavily invested in devices and technologies trying to, you know, limit, change the metabolism, how we take in calories or the pathways that are affected to modify this. Obesity, type 2 diabetes, and high cholesterol, they all kind of go along with this metabolic syndrome sort of patients. The treatment is you stay away from alcohol as much as possible. And the most important thing is weight loss, which is, you know, very difficult for these folks to really do. So there are, you know, devices from you folks, there are medications, there are endoscopic other therapies available, surgeries and so on, allowing these folks to kind of reverse this process before it goes into cirrhosis. Hepatitis C, which I mentioned, was, you know, the number one cause of liver disease in the United States before NAFLD had essentially taken over. The recommendation right now is that anybody who is 18 and older needs to get tested for hepatitis C. And the best part of it is this, which is over 95% cure rates. And I was in training not very long ago, and this was not heard of back then. And this is, you know, a big miracle essentially for hepatitis C, thanks to, you know, the research that was invested into eradicating this. Most common hepatitis worldwide is actually B and not C. It's most common in Africa and Asia. Many are unaware that they actually have hepatitis B. It just tends to, you know, spread from mom to the babies, and there are carrier stages. And many of them have a very subclinical infection that doesn't manifest, and all you find is cirrhosis sometimes in the end in these folks. So, as I said, you know, transmission can be vertical, which happens in Africa and Asia mostly sexual, also blood-borne. There is a vaccine available. You know, all kids here in the U.S. are vaccinated. And in the acute phase or especially in the vertical mother-to-child transmission phase, you could give the mom some immunoglobulin to help prevent that transfer. And there are treatments available, and there are some newer treatments coming in which could potentially cure somebody from hepatitis B. Right now, it's more so that you can get the viral levels undetectable, but the surface antigen, which is a part of the virus, stays in the blood. And as long as it is there, there is a chance of, you know, either the infection coming back at a later point or still potentially chance of the liver disease getting worse at some point down the road. But the treatment right now can prevent progression and also lower the risk of liver cancer. But in the future, there is hope that we could actually cure hepatitis B as well. So the one thing in that are interconnected between the liver and the GI disease is that in folks who have conditions that require immunosuppression, like medications that are treating Crohn's disease, ulcerative colitis, autoimmune pancreatitis, autoimmune cholangitis, all these immunosuppression medications can activate the hepatitis B. This is what I'm talking about, whether you don't have a cure, you only can suppress the antigen, suppress the viral levels. So there's a reactivation risk of over 10% when you use these biologic medications. So you do have to test them and make sure they are on some sort of – that they aren't at risk of developing the reactivation. If you do use biologics in those settings, you could risk getting an acute liver failure in those folks. So there are the – we recommend getting treatment for the hepatitis B while on treatment for – and also up to six months after discontinuing it if they were found to be positive this way. Then there is a condition called primary sclerosing cholangitis, which affects predominantly the bile ducts. It's an autoimmune process. And it's sort of unclear as to what triggers this, but they have – you know, we saw the nice pictures of the bile ducts, which looked like nice tubes. Here, they're all kind of, you know, scarred down in the middle and in the periphery, resulting in almost like, you know, beaded appearance of the ducts. And they are at risk of developing infections. They're at risk of developing cancers. So they – we tend to follow them until they develop changes in their liver tests, and then you occasionally stretch those strictures open to prevent getting infection. But also, you may need to biopsy some of these strictures to find out if they develop cancer or not. Folks who have ulcerative colitis and Crohn's disease tend to have a little bit of a higher risk of developing the primary sclerosing cholangitis. The treatment is – if it is affecting the liver, you could – they could be eligible to get a liver transplant. Gallstones, you know, I deal with this in a good chunk of my practice. It's the most common disorder affecting the bile ducts. Good population has the gallstones. And there are different types of gallstones. This is what we see predominantly in the adult population, which are cholesterol stones. So it's some sort of, you know, excessive amount of cholesterol within the gallbladder, resulting in stone – precipitation of the cholesterol in stone formation. The black stones tend to happen in folks who are breaking down blood more often than they should be. So there are conditions like sickle cell where the blood, you know, breaks down too often, and that results in the pigment getting deposited as pigment stones. The brown stones tend to be seen in more in bile duct infections. In most folks who have stones in the gallbladder, they tend to be asymptomatic. And around 2% to 3% or so is your risk of getting a biliary colic. Colic is when you have pain in your right side or in the upper abdomen after eating. And it can last, you know, a few minutes to a few hours, and typically connected to some sort of eating. You could go up to the right shoulder or go up to the back. And once you develop a colic, there is a high chance that you could develop cholecystitis, which is inflammation of the gallbladder, or you could develop other problems related to the bile duct, where the stones can essentially drop down into the bile duct. The way you diagnose stones in the gallbladder is just with a regular ultrasound on the skin. So you just scan the upper abdomen. You can see the gallbladder fairly well in most patients, in most individuals, and you can see a bright structure with a dark shadowing down, and that is how a stone looks. And as I said, those who develop colic are at a higher risk of developing obstruction of the cystic duct, the duct that connects the gallbladder to the bile duct, resulting in inflammation of the gallbladder. That's called cholecystitis. And once you develop cholecystitis, you could manage them, temporize them with antibiotics, but very often you would need to do surgery on them. And the way you diagnose, again, is with the ultrasound, and now you're seeing thickening of the gallbladder wall. You see sometimes some fluid around the gallbladder, also suggesting inflammation of the gallbladder wall. And when you do the gallbladder surgery, they are essentially clipping the cystic duct and taking away the gallbladder. There's a little bit of dissection involved, and the majority of these procedures are done laparoscopically. In folks who are not surgical candidates, there are other alternatives available where you could do radiology doctors will put a tube through the liver into the gallbladder. That's called PTC, or percutaneous transhepatic cholecystostomy, and they leave it connected to a bag on the outside, and sometimes they can cap it off and let it rain inside once the inflammation has resolved. It's usually used as a temporizing measure before they go for surgery. In folks who are permanently not surgical candidates, we could also use endoscopic ultrasound to drain the gallbladder. As you can see, it's really up against the duodenum, and you can place a stent to drain the gallbladder into the duodenum using endoscopic ultrasound. So that's another novel treatment that we offer for patients. Bile duct stones, they are migrated stones from the gallbladder into the bile duct. They do present with pain, jaundice, and fever. This is the pepula, and this is how you do the ERCP and take the stone out. You do a cholangiogram. You find the stone, and you use accessories to pull the stone down. You also open up the opening a little bigger by using cautery, and that's called sphincterotomy. Pancreas inflammation can present in two forms, acute or chronic. Acute is somebody who's coming in with severe pain. They're usually in the hospital, or chronic pancreatitis, people who have had multiple episodes lead to chronic inflammation. The symptoms in mild to severe, it could range from, and the severe ones are some people who are in the ICU. They can result in multi-organ failure, and it can actually even lead to death. About 30% of the folks who end up with a severe pancreatitis can lead to, can even die from pancreatitis from multi-organ failure. There are various causes of acute pancreatitis. The majority of them are gallstones and alcohol. We say in women, gallstones, and men, alcohol. Those are the two main causes of pancreatitis. Not that it cannot happen the other way, but most common, women, gallstones, and men, alcohol. High triglycerides, medications, blunt trauma to the pancreas sometimes can result in pancreatitis. Autoimmune causes, some other etiologies, and ERCP can result in pancreatitis, which is, again, another thing we see more often because we do ERCPs. We tend to see that a lot. There are blood tests you can use to diagnose. Lipase and amylase increases the increase in pancreatitis. Also, you can do scans to diagnose acute pancreatitis. The supportive care is made the mainstay treatment for acute pancreatitis. You give fluids, pain management, and just try to get them through that period of time. Occasionally, they get complications to the point where they're developing large collections or infections, which require, again, some endoscopic drainages. If it is gallstone pancreatitis and there are still stones blocking the bile duct or the junction of the bile duct with the intestines, you could do ERCP to take those stones out. You know that based on ultrasound showing that the bile duct is bigger or the blood test showing that the liver tests are high. That will tell you that indication to do an ERCP in that setting. Chronic pancreatitis, on the other hand, is longstanding inflammation of the pancreas. These tend to be folks you would see more in the office rather than in the hospital, but occasionally, they can develop acute pancreatitis and can still present in the hospital. We talked about the exocrine and the endocrine function of the pancreas. Exocrine losses result in not enough enzymes to digest food, and therefore, they lose fat in their stool, resulting in what we call steatorrhea, which is excessive fat in the stool. They lose weight. They're malabsorption, essentially. They're not absorbing calories, so they're losing a lot of weight that way. In endocrine form, one of the big ones is diabetes because of the inability to process glucose adequately. X-ray can be used to diagnose chronic pancreatitis. A lot of calcium you're seeing, just like the bones are white, and same way the calcium will be white, so it will come up on the X-ray this way. You can also see on the CAT scan, same thing, calcifications, but you can also see the pancreatic duct being more enlarged, suggesting chronic pancreatitis. Treatment for that, smoking is a big deal. It leads to a lot of scar tissue formation, inflammation, so you do want to avoid smoking in these folks. Stay away from alcohol if that is a cause, or it could precipitate further worsening. You replace the enzymes in those who have steatorrhea, and then pain management. You could also do celiac block in these folks, where you're essentially injecting anesthetic medication around the nerves, around the pancreas, essentially, that will lessen the irritation. You could also place a stent in the pancreas. If there's excessive pressure in the pancreatic duct from these stones and the calcium-causing blockage, you can place a stent and relieve that blockage, and relieve that pressure, and that can sometimes help with the steatorrhea, but also help with pain. Ultimately, surgery is a longstanding treatment, but it's very difficult to do surgery in these folks because of all the inflammation. Pancreatic cancer, it's not a very common cancer, but it leads to a lot of deaths because there is not much treatment available for it, and many times when you detect them, they are already in a much more advanced stage. One-year survival after the cancer is 25%, and five-year survival is about 6%. And there are several risk factors, smoking alcohol being two preventable risk factors in these folks, and family history is something, obviously, you don't have any control over. They could present with painless jaundice, weight loss, and if they have blockage of the bile ducts, they can have itching, and jaundice, obviously, if there is blockage of the bile ducts. They can also have pain, and nausea, and vomiting if there is blockage of the intestines. So just like we saw in the other pictures of taking a biopsy of the lymph node, you could take a biopsy of the tumor using the endoscopic ultrasound with a needle. Surgery is a mainstay treatment as long as they are candidates for surgery, and many folks require chemotherapy before surgery as well, just because they tend to be a little more advanced. A lot of blood vessels in that area as well, you try to want to shrink it a little bit before going for surgery. If they have blockage of the bile duct, you can place a stent to relieve the blockage. And this is how the stent looks once it is placed. This is on x-ray, and this is how endoscopically it may look. And that's it. We made it in time. Sorry, I had to go really rapid fire on that one. Questions? None. Oh, OK. I have one. What are you currently doing for your ERCPs to help prevent pancreatitis? All right. So there are a couple of measures that we do routinely for all folks who get ERCPs. We give them fluids generously as long as they can tolerate, and we also do suppositories of indomethacin. So these are anti-inflammatory medications that if you're given around the time of the procedure, it reduces your risk of getting pancreatitis. If we accidentally get into pancreas, and our goal is to do a bile duct study, but we accidentally went into the pancreas, we almost always leave a stent in the pancreas, which also protects the pancreas from getting pancreatitis. So those are three measures that we know can reduce pancreatitis risk, which is fluids, indomethacin suppositories, and the pancreas duct stent.

liver diseases

cirrhosis

non-alcoholic fatty liver disease

hepatitis C

pancreatic cancer

gallstones