Hello, everybody. Good morning. I am Kajali Mishra. I am one of the doctors taking care of patients with inflammatory bowel disease at Stroger Hospital. That's the Cook County Hospital. I'm going to be giving a quick anatomy lesson on the organs that are kind of sitting here in the center of your abdomen. So this picture I kind of, you know, it's like a person standing towards you. So the liver is to your right. And then you do have your, I don't know how this pointer thing works, but I'm going to try. Oh, here you go. So then your liver is to your right. And then you have your gallbladder sort of hiding behind the liver. And you've got your pancreas right below it. In terms of the continuity of, you know, of the GI tract, so all the way after you eat your food, it goes into your food pipe, which is your esophagus, then stores in this large organ, which is your stomach, and then goes into your small intestine. You can see that the pancreas is sort of connected to your small intestine. We'll talk a little bit about that. And then your small intestine is kind of over here in the center, and then goes into your large intestine, which kind of tracks to the side, transfers, sorry, my cursor is failing me, but it goes transfers, and then it goes down, and then you poop. So that's kind of how the food is going all around after you put it in your mouth and you've done a lot of chewing. So my goal today is to kind of tell you a little bit about liver and the pancreas. So liver is one of the most important organs of your GI tract. So it's a pretty heavy organ, it's a solid organ, and a very vascular organ, and occupies a major area of your right upper quadrant. And it kind of sits there. And as I showed you in the picture, the gallbladder is behind it, so the liver has kind of a scalloping in the back. So over from the front, it is kind of round and smooth, and then a little scalloping, which holds the, which is kind of the base for the gallbladder to sit. It's about four pounds, and as I said, it's a very vascular organ, so most organs have a single blood supply coming in the artery, getting the fresh blood to the organ. This one has a hepatic artery and a portal vein, so two major blood vessels supplying this organ. So the liver, I'm going to just use my hand, the cursor is not my thing. So we have the right lobe to your right, kind of if someone's standing looking at you, so the right lobe is to your right, and your left lobe is towards on this side. As I showed in the picture, the gallbladder is, the gallbladder is behind the liver, and then you have your gallbladder kind of continuing in terms of your bile ducts down, and your pancreas is over here in your stomach. If you try to kind of see or understand where it is, your stomach is over here, your liver is over here, and then your pancreas is on an incline, kind of like a slanting. So a part of it is behind the stomach, the tail portion is behind the stomach, and sort of the head portion is below the liver, kind of opening into the duodenum, which is the part of the small intestine. So this is trying to show you, this picture or diagram is trying to show you two things. One is the blood supply. So in the center, you see it's a very busy area. That's where the arteries are coming in, which is red, the blue are the veins, and then the green is the bile system. So you have your portal vein entering, and then you have your red hepatic artery entering, and both of them are, their job is to supply this really vascular large organ, and then the blood after the supply, the deoxygenated blood, or the blood that has to go back to the heart to freshen up, goes through the hepatic veins, and then the veins take it to the heart. So you can imagine that if there's any problem with the liver, or if there's any scarring of the liver, or fibrosis, or end-stage, what we call a cirrhosis, this thing is going to be all scarred. So this blood supply will not happen as smoothly. So the blood will get to the liver, because that's not where the problem is, but it won't get back, and there will be backup of this blood. So your major blood vessels now are storing all this blood, which is not moving forward. So that's the blood supply. In terms of your bile production, so liver is responsible for producing bile. That's the green substance. You often hear your patients telling, I vomited just pure bile, which is this green, kind of green-yellow stuff that they cough up. So this bile is produced in the liver, and you see these very tiny green ducts kind of collecting that bile from all these canaliculi, and then making two major ducts. So it's coming from the right side is your right duct, left side is your left duct, and then makes your common hepatic duct. This gallbladder, and someone asked the question, where do bile store? So after the liver produces the bile, until you're ready to secrete the bile, which has to be timed really well, because bile is very important for digestion of a lot of things, and we'll talk about that in a little bit. But it'll store in the gallbladder, and when the time is right, your gallbladder is going to squeeze, and that bile is going to come down, be secreted, along with all the pancreatic stuff into your duodenum, and that's where the digestion happens. So the body has to really time it well that the food gets to the duodenum by the time all the enzymes are also down there, so that that mixture is ready to be digested and then absorbed. So this is kind of what I showed you, again, ducts, the hepatic ducts, and then gallbladder. The cystic duct is that small duct that connects to the gallbladder, to the common bile duct, and then ampullae is where everything opens up, your pancreas, your bile, and again, it opens into the duodenum portion of your small intestine. Bile is green-yellow, stored in the gallbladder. There is a CCK, a cholecystokinin, it's a hormone that's secreted by your small intestine, and whenever you eat a real nice fatty meal, this cholecystokinin will come out, and then it will cause the gallbladder to contract, and then all that stuff, the bile, will come in into your duodenum. It is this bile portion, so from the top, and we talked a little bit about this before, the digestion, the chemical digestion part, is done by saliva in the mouth, acid in your stomach, and then your bile and your pancreatic juices over here. So the actual movement, the peristalsis, is not a part of the chemical digestion, but these enzymes are the ones that are responsible. Bile is particularly responsible for fat digestion, and ADEK are the vitamins that are responsible, they're fat-soluble, so when the fat is digested and absorbed, these vitamins absorb. So anyone who has problems in the whole system, where the liver, the gallbladder is a problem, bile system is a problem, or the duodenum is a problem, or this thing, the whole mechanism is not happening properly, then you could have malabsorption of the fat, and then the fat-soluble vitamins. Quickly about the liver function, it's responsible for a lot of things, but producing glucose, the substance that gives you energy, immediate energy, proteins, which is the muscle mass, cholesterol, good cholesterol, and there's good and bad cholesterol. Cholesterol is very important because a lot of the structure of the very basic cell is made by the cholesterol. So it does all of that, it also helps in blood clotting, so patients who have problems with the liver, so cirrhosis or fibrosis, they do not have enough energy because immediate glucose production is not happening. Their blood is thin and they're not able to, you know, they bleed a lot if they tend to get hurt, you know, and then they bleed a lot because of this problem. So this is the job of the liver to produce, then another job is to store. So when there is excess of the glucose, it will prepare itself for later, so it'll store and form the glycogen, it'll also store a lot of vitamins, so A, vitamin D, B12, and K. Your iron and your copper are also stored by the liver. It's also responsible for breakdown of, or what we call as the first pass, where what we eat is getting into your stomach and then getting directly into the blood vessel. These blood vessels are going through the liver, so it's kind of like a sieve, it's making sure that, you know, anything that's a straight toxin, the liver takes the hit, removes it, or tries to, like, break it down. So certain medications, you know, go through the liver and can potentially damage the liver, and that's why monitoring of the liver is done with certain medication, which we know are going to absorb through the stomach route. Alcohol is a big, you know, is a big factor for liver damage, alcohol-related liver disease is pretty common, and then we have, you know, certain toxins, like, again, certain medication groups can be toxins, certain herbal medication could be toxins to the liver as well. We can now move on to the next organ, which is your pancreas. This is the pancreas, you know, it's kind of, I try to show you the stomach sits on to the pancreas, where the body and the tail portion is, and it's in form of an incline, so you see the head, and then the neck, and then the body and tail, so tail behind the stomach, and then your head is kind of here in the center. Again, the opening is into the duodenum portion, which is the small intestine, and you see your main pancreatic duct kind of draining into it. It also has a little uncinate process, and there is some significance to it, but nothing major that you need to know. So in terms of what the, what pancreas does, it has got two major groups of function. One we call it exocrine, one is endocrine. Endocrine is mostly its hormonal portion. Exocrine is what's required in the GI tract for digestion purposes, so you can see that the enzymes that it is producing is breaking down a lot of things, so fats, carbs, protein, which is pretty much what you all eat. So it's responsible for digesting pretty much all major constituents of your food, and then the bicarb, it also produces the bicarb, so stomach is producing a lot of acid, and then the pancreas is producing bicarb, so bicarb is base, so as soon as your food, which has the, which is mixed with all the stomach acid, enters into the duodenum, this bicarb will kind of neutralize it, and then help kind of, you know, neutralize the effect of that acid so that the small intestine is protected from it. It also has other function, which I'll discuss in a minute, but coming on to the endocrine portion of it, so endocrine is the hormonal portion, so it's all, it's responsible for producing the insulin, the glucagon, and somatostatin. Insulin, as most people may know, diabetics have problems producing the insulin, so anyone who has problems with the pancreas will have issues with digestion, so they will not digest a lot of components of the food, so they'll have malabsorption, they'll start losing weight, and all of the food they eat unprocessed will just kind of come down in the form of stool, so they have really, you know, just that kind of nasty smelling stool, which is not well-absorbed, and all the food is still pretty much in there, not broken down, and then it also, that will be the problem when your pancreas is not working, the other problem is then they start developing diabetes, because the insulin is also secreted by the pancreas, and that does not happen. Glucagon sort of works opposite to the insulin, you know, so, you know, in terms of its function, but it's also secreted by the pancreas, and then another hormone is somatostatin. So secretin is an important hormone, so I'll kind of walk you through what happens. So as I said, the food that's completely mixed with the acid from the stomach, when it enters into the small intestine, the small intestine senses that acid food, and then it secretes the secretin, so the small intestine is secreting this hormone, which is then going into the blood, and then stimulating your pancreas, and it's just telling your pancreas to secrete something to neutralize that acid, and that's going to be a bicarb, and it neutralizes the acid, and then kind of breaks the chain of secretion of secretin, and in addition to this bicarb, it is secreting all that pancreatic enzymes, which is helping with the digestion, so it's kind of a cycle, so after you eat, once the, you know, once the food stops coming in, or once it's neutralized, this cycle will be stopped, and the digestion cycle will be complete. So in a nutshell, GI tract has a lot of, you know, function. It's breaking down all the food that you're eating, and then it's absorbing everything. The absorption of water and mineral happens mostly in your colon, so the bile, the pancreas, it's not, and the liver mostly is really not doing anything to the water, so absorption of water is the job of your colon, not a job of your liver. Then the motility or the peristalsis take the food forward, but again, it's not a form of the chemical digestion, that's with the acid and all the other enzymes we talked about, and then it stores your food, which is the waste after everything that's good and useful is absorbed by your body, and then it stores it until it's ready in the rectum, and then you're ready to go, boo-boo. Okay, what questions do you guys have? How do you, I'm thinking like preventative health, just given like the prevalence of medications and alcohol consumption in our society, how do you measure the health of the liver preventatively before someone has symptoms of a progressive disease like cirrhosis or something like that? Are you using blood tests for liver health? Are you doing ultrasound? How do you usually approach that from a preventative standpoint? Yeah, that's an excellent question, and a lot of work has been done to kind of take the liver health to a preventative phase, and we are sort of in the reactive phase still. When we see liver tests elevated, we sort of react to it, trying to find what's the cause, and then we probe our patients to get that history of like, oh, have they been taking any certain medication, anything over-the-counter, herbal supplements, or drinking excessive alcohol, and then we kind of gauge what the problem might be, but liver, all these things are damaging to the liver, but there are intrinsic problems that could happen, like autoimmune conditions that can develop in the liver, so those can be a cause of the liver damage as well, and then there are viral causes as well, like hepatitis virus itself can damage the liver. So once we see the liver enzymes elevated, then we kind of react to them by checking those things and kind of ruling those things out. In terms of the preventative aspect, certain diseases we know now with the metabolic syndrome, we know obesity is very prevalent, so in those patients, we are more vigilant, and we tend to check the liver enzymes at least once to make sure there's no inflammation. Sometimes if patients are complaining of certain problems or symptoms related to the liver, that may lead to some of the testing. In terms of even if the liver enzymes are not elevated, would I go ahead and do certain other blood work? Probably not. Less likely, but if my suspicion is high or some scan has shown a condition that makes me concerned, especially if my patient gives me a pretty significant history of alcohol use or certain toxins that could damage the liver, then I'm at least doing a liver test and then maybe taking a step forward to doing some sort of assessment of the scarring. So there's fiber scans to assess the scarring of your liver, or elastography just to kind of get a sense of how scarred is the liver, and then we kind of grade them from like one to four where they are to help them kind of see if they're three or four, that's bad. One or two is early, so there's data to see that there's data support that this might be a phase where if it's certain conditions, we could reverse them, especially obesity. Yeah. Dr. Yoon previously mentioned how like some of the intestines and things like that, how they have patients that easily like bleed or things like that. For any patients that you all see, if they bruise easily, you know, have issues with clotting or anything like that, is that solely based on the lack of those clotting factors coming from the liver, or can there be other like outside factors or lack of other cascades that affect that type of clotting in the patient? Yeah, that's a very good question. It's a pretty complex mechanism, the whole bleeding and clotting, and as you mentioned, there's a whole cascade. So there are steps to clotting, so whenever an injury happens, there's an immediate reaction to that area by first your platelets, which is a part of your, you know, blood counts. So the platelets kind of stack one over the other, and then products are released, some from the platelets itself, and then some are dependent on organs, mostly liver, which are the factors that come out, and then they kind of go from step one to step two, step two to step three, basically making this friable area a more, you know, developing a clot, which is a more kind of solidified, if you will, you know, thing to protect that area from bleeding further. So if any of those things are missing, then the clotting mechanism may not happen properly. So if you have issues with platelets itself, or if you have issues with the tissue itself, or if you have issues with the liver. So when a patient comes in solely just complaining that they have problems, they're bleeding a lot or bruising a lot, we're keeping liver as one of the possibilities. So we're checking, you know, something what we call as coagulation factors, but then we're usually asking, phone-friending our colleagues over on hematology, asking them, making sure, you know, we're not missing anything, because it's kind of like a multidisciplinary thing if the problem is only blood clotting or easy bruising. Yep. Question about the pancreas. With pancreatic cancer being as deadly as it is, is there any, like, warning signs or anything that you guys see early on that kind of you look at and investigate early on in the symptoms with the pancreas? That's a very good question. So pancreatic cancer screening, you know, there are patients who qualify for pancreatic cancer screening, and they're usually when you go see, you know, even your primary care doctor, once you mention your family has a history of pancreatic cancer, that kind of starts like, you know, that raises our antennas, that, you know, because there are certain conditions when clubbed with the family history, we know we need to start screening. Certain conditions like, for example, Lynch syndrome itself, if you have that syndrome, then you qualify for screening for pancreatic cancer. Having said that, you know, if we remove the genetic causes of pancreatic cancer, environmental, you know, exposure or damage is a major reason that patients are, we are seeing more incidents of pancreatic cancer now. So we often take the extra step of counseling, you know, against smoking, because smoking physician has to be shown to be protective. And alcohol damage, you know, alcohol causing chronic pancreatitis, and then multiple bouts of chronic pancreatitis can cause them to develop cancer. So when we see a patient who is at a higher risk, we can take that extra step. Sometimes when we see abnormalities, you know, or if they start having symptoms related to stool or any other issues or malabsorption, then we tend to, you know, either check their stool or do a quick scan that could include an MRI even, or an endoscopic ultrasound to look at the pancreas to make sure we're not missing anything. So again, there are different ways that we approach this depending on at what risk we think the patient is at. But at this point in time, there's no like kind of age cutoff to say that, you know, like colonoscopies at age 45, we're not doing that as a routine screening. So we're almost all gastroenterologists are taking that extra step to make sure that we're kind of counseling our patients to remove at least the risk factors for pancreatic cancer. Mm-hmm. Okay. Very good. Thank you so much. Thank you.

abdominal organs

liver functions

pancreas roles

digestion

liver health

pancreatic cancer