Thursday 3 September 2020
My Amazing Body is a podcast where we explore interesting, unknown and misunderstood parts of your body with help from medical experts and stories from real Queenslanders.
This episode is all about your liver. Where is your liver, what does it do and how can you keep yours healthy? We hear from Princess Alexandra Hospital surgeon Dr Peter Hodgkinson about why someone might need a liver transplant and how he performs them, and get his advice for ways to avoid ending up on the operating table. Then, Queensland man Jordan takes us through what it was like to have a liver transplant as a teenager, after living with a low-functioning liver throughout childhood.
Meet our guests
Audio is great, but some things are best seen as well as heard, or might tempt you to do further reading. These materials provide more information about topics we touch on in the show.
Hepatitis C treatment
In the episode, Dr Hodgkinson talks about new, very effective treatments for hepatitis C that have been developed over the past few years. You can find more information about hepatitis C and treatment options at the links below:
Fatty liver disease
When he talks about reasons Queenslanders might have issues with their liver health or require a liver transplant, Dr Hodgkinson mentions fatty liver disease as a growing health issue. You can learn more about fatty liver disease from Health Direct and Liver Foundation Australia.
Liver transplants and becoming an organ donor
In this episode, Dr Hodgkinson and Jordan take you through what it’s like to have a liver transplant.
Both our guests encourage Queenslanders to consider signing up as an organ donor. You can find more information about how to sign up through Donate Life.
Host: Dr Peter Hodgkinson is a liver transplant surgeon at the Princess Alexandra Hospital.
Dr Hodgkinson: Well, the worst part's probably getting up at 2:00 in the morning to do operations. But in some ways, that's also the best part of my job.
Host: Dr Hodgkinson has one of the coolest jobs in medicine - giving people lifesaving liver transplants. And, he loves it.
Dr Hodgkinson: I mean, I think I'm very fortunate in that I have a job that I love. And every day that I come to work, I count myself lucky for having this possibility of doing what I do.
Host: But how do people get to the stage that they need a liver transplant? And, is there anything you can do to prevent yourself from ending up on Dr Hodgkinson's operating table?
Welcome to this episode of My Amazing Body, a podcast that explores interesting, unknown and misunderstood parts of your body. Today, we're learning about your liver.
Your liver is one of the most important organs in your body, but you might not know much about it. We asked Dr Hodgkinson to give us the basics: where is it, what does it look like and what does it actually do?
Dr Hodgkinson: So, the liver is a large organ. In fact, it's the largest solid organ in your body. It sits inside your tummy and it sits in the upper part of your tummy. And as I said, it's a very big organ. It weighs about one and a half kilos.
Host: To put that in context, your liver weighs about the same as a small chihuahua, or a cricket bat.
Dr Hodgkinson: So, the liver is a nut-brown colour. It's very soft like a sponge, and the edges of it are normally a very sharp well-defined edge.
Host: Your liver grows with you as you age - a baby's liver is much smaller than an adult liver. And that's not the only growing it can do - if you have part of your liver removed because of disease or injury, it can actually grow back.
Dr Hodgkinson: So, your liver is actually made up of eight different pieces, doctors call them segments. And each of these eight segments has its own artery and vein and blood supply. And each of those eight segments can function individually to the other segments in the liver. So, I can do an operation where I remove one of the segments or even more, sometimes up to six segments of the liver can be removed. And the other two segments will continue functioning just like they always have. And these segments will grow bigger. And they will grow back. They'll grow so big that they actually grow back to the normal size of the liver. Now, you'll only have two segments, but you'll have two very big segments, so you'll have a normal sized liver. And this regeneration capacity of the liver is quite amazing and is unique to the liver.
Host: So, your liver is big, really big. And it can regrow on its own. That must mean it's pretty important, right?
Dr Hodgkinson: It has many functions. In fact, it's sort of estimated it has about 500 different functions. And so, as you can imagine, it's a very important organ and you can't live without it.
So, it makes certain proteins, which help us do our bodily functions. In particular, things like clotting the blood or helping us regulate our energy intake or our energy expenditure. It also detoxifies our blood. So, a lot of the toxins from the environment are removed by the liver. It also helps in the digestion of food. So, it makes a liquid called bile. And the bile is excreted into the bowel, where it helps us break down food. And it also has a number of functions in making and getting rid of old blood cells.
Host: As Dr Hodgkinson says, you can't live without your liver - if your liver gets sick, you're going to know about it.
Dr Hodgkinson: So, if your liver's not working, you feel pretty terrible. So, as I mentioned, it helps with making proteins and hormones and energy regulation of your body. So, if your liver's not working, your management of energy regulation is very out of whack. So, what you experience is people often feel very tired with no energy. They find they have to sleep more. And so, from an energy point of view, that occurs. A lot of the other functions also go out of whack. So, you can have decreased amounts of protein made in the body. And one of the outcomes of this is that you retain a lot of fluid in your body. And so, people with liver failure can have very swollen, particularly legs, but all over their body can be quite swollen. They don't tend to absorb food properly or nutrients properly. And so, that also impacts the way you feel.
Host: Have you ever heard of jaundice? It's a symptom that quickly shows you something's not quite right with your liver. It's hard to miss, because it literally means you start turning yellow.
Dr Hodgkinson: And one of the big things that people notice when they have a liver that's not work is that they can turn yellow, which doctors call jaundice. And it's because the liver that normally would make bile and excrete bile into the bowel is not making bile properly, so all of those toxic elements that normally get excreted out in the bile build up in your body. And you turn yellow. You can have yellow skin. Your urine can actually turn a very dark colour, like tea. And often the bowel movements or stool actually becomes quite pale.
Host: It's pretty common for babies to be born with jaundice, and while most of the time it's not a huge deal, but Dr Hodgkinson says the condition always needs to be checked out.
Dr Hodgkinson: A lot of babies can be born jaundiced and it's related to the haemoglobin in babies before they're born. So, haemoglobin is the red part of your blood that carries oxygen around. And a foetus, so a baby before it's born actually has a different type of haemoglobin. And the other part of it is your liver function takes a little while to deal with this haemoglobin that you have differently as a foetus. And so, when you're first born, you can actually have this yellow colour related to the liver dealing with this different type of haemoglobin and it fairly rapidly clears, but in some babies, it can take a little while.
Host: Biliary atresia is one of the most common causes of liver failure in kids. It happens when a baby is born without a bile duct.
Dr Hodgkinson: The bile duct is a little tube that runs from your liver to the bowel and it takes bile from the liver to the bowel. And if you're born without one of those, then you quite rapidly develop liver failure as a child.
Now, there are other reasons that children can be born with jaundice apart from biliary atresia. And most of these actually are quite serious conditions as well. So, if a child is born with jaundice, they actually need to see doctors quite quickly. And if it persists, it needs to be looked into by an experienced paediatrician quite quickly.
Host: There are quite a few diseases that can affect your liver health. While some can be prevented, unfortunately some of them just happen and there are no real ways to prevent yourself from getting them.
Dr Hodgkinson: In terms of other things that can occur any time when you're a child or an adult, there's a number of illnesses. One that is relatively common for patients, if they have it, is called cystic fibrosis and that can affect your liver. There is a number of other enzyme processes within the liver that can be affected. And there's one called Alpha-1 antitrypsin deficiency. There's a number of other genetic causes, which affect the bile production and liver. There's one called primary biliary cirrhosis. And there's a number of autoimmune conditions that can affect the liver as well. One's quite usefully named autoimmune hepatitis. And then there's another one called primary sclerosing cholangitis. But as I mentioned, there are many, many, many things that can actually cause disease within your liver because the liver has so many different functions.
Host: If you start having symptoms that show your liver isn't working properly, you'll be referred to a specialist called a hepatologist to get a diagnosis.
Dr Hodgkinson: And there are many, many tests that we run on patients to work out what is the cause of their liver disease.
Now, sometimes it can be found very quickly because it's one of the more straightforward and common liver diseases. And then at other times, if it's a rare disease, it can be quite hard to find what the cause is. And sometimes that can take days or weeks or even sometimes months before you find out what the cause is.
Host: Every year, Dr Hodgkinson performs liver transplants on patients who have incurable diseases that have damaged their livers. But he also does transplant operations on people whose livers are unwell because of their lifestyle choices.
Dr Hodgkinson: So, the most common reason for liver transplant in the past has been hepatitis C. However, with the new treatments that have come out, there's a number of new treatments that have come out for hepatitis C and these have been very effective. We now are seeing a big decrease in the amount of patients who need liver transplants for hepatitis C. And we're seeing an increase in patients who need transplants for fatty liver disease. The most common reasons for liver transplant is hepatitis C, liver disease due to alcohol and fatty liver disease.
Host: Fatty liver disease is exactly what it sounds like: it happens when your liver gets overwhelmed by fat build up and can't operate properly.
Dr Hodgkinson: When you have fatty liver disease, the liver changes colour and it becomes quite yellow like fat. It gets bigger in size, so it actually is bigger than it normally would be. And it becomes quite firm, more like a rubber ball, rather than a sponge. And the edges of the liver, instead of being sharp and well-defined, become very round. So, it turns into a bit of a round yellow ball.
Host: Dr Hodgkinson says his job isn't to judge someone for their liver condition - in fact it's surprisingly easy to damage your liver living in our modern world.
Dr Hodgkinson: I see people who, for various different reasons, and it's usually not their fault, but they've had things happen in their life and so their health has gone onto the back burner a little bit and they may have drunk too much alcohol or smoked or put on weight. And it's affected how they are living after that. And then some of them have even ended up having to have a liver transplant.
Host: Are you ready for this episode's mystery body part? I am a thin string of tissue. In the womb, I guide the growth of a baby's mouth. Saliva can erupt from glands at my base, a process called gleeking. If I'm unusually tight, I can cause issues with feeding early in life. Do you know what I am?
Host: Liver failure occurs differently from person to person. For some people it takes years to develop, and in others it can happen quite suddenly. Regardless of the cause, if you have liver failure, a liver transplant is your only treatment option to cure the condition.
Dr Hodgkinson: There's a number of ways that people can develop liver failure. It can either be a chronic process like cirrhosis, where it takes a number of years to occur. Well, you can actually develop liver failure very quickly, what we call acute liver failure. And this is often related to an infection or sometimes a drug reaction or a toxin that can affect the liver very quickly. And these people, within a matter of days or weeks can actually have acute liver failure and need an urgent liver transplant.
Host: A liver transplant is a big operation, and it requires a large teams of specialist clinicians.
Dr Hodgkinson: So, with a liver transplant, it involves a very big team of doctors and nurses and transplant coordinators and a number of different hospitals. So, each time an organ donor becomes available, it sets in motion a very big chain of events. So, tragically for transplant to occur, a patient somewhere has to have had a terrible accident. Now, it might be that they've had a car accident or some other traumatic injury, or it may be that they've had something medically happen such as a stroke or some other tragic sort of medical condition which has caused their brain to fail.
Host: Not every donated liver will be right for every person requiring a transplant. A large adult liver won't fit in the body of sick child, for example, and the donor and recipient blood groups need to match up. Once the transplant team know the donor details, it's all about finding the right match as soon as possible.
Dr Hodgkinson: Once that's done, we then decide which of the people who match that liver are the sickest patients and who are needing a transplant most urgently. And that's the person who will receive the transplant. So, you can see that there's lots of decision making and lots of phone calls and decisions around this. Once we've decided who the recipient is going to be, our coordinators will call the person and they will come into the hospital. And at the same time, we'll send a team of doctors out to the donor hospital to do the donor operation. And typically, this takes place at all times of the day. But it can often happen in the middle of the night, early hours of the morning. And so, we have people going all over the state, perhaps flying to Cairns or Townsville or Rockhampton to do donor operations.
Host: While surgeons fly to carefully remove and transport the donated organ, Dr Hodgkinson's team at the PA begin to prep their patient to receive their new organ.
Dr Hodgkinson: So, at the donor hospital, we'll do the operation, remove the liver. It has all the blood flushed out of it. And it has preservation fluid put in it. And then it's put in an esky in ice. And we keep the liver cold until we bring it back and do the transplant. While we're bringing the liver back to PA, there will be another team of surgeons here at PA who will have already started the liver transplant, and they will be removing the patient's old and cirrhotic liver. And then we'll be putting in the new one when we arrive back. All up, the process can take perhaps as long as 24 hours or more from when we first get called about the donor until when we actually do the transplant.
Host: Four years ago, Queenslander Jordan was one of the lucky recipients of a liver transplant when he was just sixteen years old. Born with a condition called Alagille Syndrome, Jordan lived with worsening affects from his unwell liver for his whole childhood.
Jordan: When I was born, I have a twin brother as well, and we both came out a bit jaundice and so under the little UV lights that they do, they found that my brother's went away and mine didn't and then they looked into it and I was diagnosed with Alagille Syndrome. That one's a multi organ condition and that can affect all the organs. In my case, it was mostly my liver as well as a heart murmur as well.
Host: Jordan's condition affected his ability to do normal childhood things, like attend school, do sports and hang out with his friends.
Jordan: For myself, it was more to the point of quality of life so for the first 16 years of my life, I was very lucky to make it to school four days a week. I wasn't able to interact into sports like contact sports and all of that so I was kind of missing out a lot. I'd miss out on a lot of schooling as well.
Host: When he was in year 10, he decided it was time to go on the transplant list, but it would be 22 months until Jordan's perfect-match liver came along.
Jordan: I'm usually a heavy sleeper so it was really weird because that night, I think it was about 1:00 AM or 2:00 AM in the morning, that we heard this phone call on our home phone and I was just lying there and then, hearing the phone, I jumped up and went straight to the phone. I was like, "Hello? Hello?" And they were like, "Hi, is this Jordan Bade?" And I was like, "Yes, speaking." And they were like, "We think we might have a liver for you." And then everything just felt like it stopped. I couldn't believe it, I was just like, "No way that they have a liver for me." We'd been waiting for so long, which is fine because they have the perfect one for me. And then in came my parents into the kitchen and they're like, "What? What? What's happened?" I'm like, "They have a liver." And it was so emotional. I was like, "I don't know if I can do this." And they were like, "Just grab some stuff together and come down to the hospital."
Host: A few hours later, Jordan was at the hospital, waiting for the surgery that would change his life.
Jordan: The really special thing about it was that they said that I'd be sharing a liver and they said it would be with a little baby. That was so special to know that I'm sharing this special gift with, not just myself, but with someone else who has now also been able to have a new quality of life. And so, it was a whole lot of emotions and because I was 16 at the time also, I was like, "I really want Mom to come in with me till I go off to sleep." Because I was 16, they were able to accommodate that and so Mum was with me the whole way as she has always been since day one. That was pretty reassuring and yeah.
Host: Dr Hodgkinson explains that a liver transplant is not a quick or risk-free procedure. His patients are often very sick and have to be monitored carefully by anaesthetists while they're put to sleep. After they're asleep and stable, he and his team get to work.
Dr Hodgkinson: Once they're asleep, then I'll make an incision on the tummy. And it's quite a big cut. It starts just under your ribs in the middle. And then it goes down towards the belly button and then goes across to the right-hand side. So, it's a big L shape. And sometimes we even need to make it bigger and we have to go across to the other side and it's what we call a Mercedes Benz incision. It looks like the symbol for a Mercedes Benz. And so, that means we've completely opened all the muscles of the tummy wall just to get to the liver.
Host: One of the many jobs of your liver is to make a protein that helps your blood clot. This means patients with liver failure will often bleed a lot during surgery, but there's an ingenious tool that Dr Hodgkinson's team uses when this happens.
Dr Hodgkinson: So, very frequently, there's a lot of bleeding during a liver transplant. We actually have a machine, which is called a Cell Saver, where when blood bleeds out of blood vessels, we suck it up through a sucker and it's collected in this Cell Saver. And this blood is then washed, and it's returned to the patient. So, this is a way of saving people's blood while they're having a transplant. We actually have a couple of people who just run this Cell Saver machine for us while we're doing the operation.
Host: About six hours later, the transplant is complete, and the patient begins their recovery journey.
Jordan: After the transplant had happened, I think I was in surgery for about four hours, and I think it was still a couple of days before I came to, all the anaesthetics and making sure that everything was fine. I believe I was in ICU for like two days and then they put me onto the ward. Waking up and everything, realizing that I no longer felt icky in the tummy anymore, having a roommate as well was pretty cool because they'd also just gone through a transplant so we were able to talk to each other and, "How are you feeling today?" And, "How are you feeling?" All the blood tests as well and just making sure that levels were fine. I think when I realized that everything was getting better was I think I only spent about a week, a week and a half, or something in the hospital and then I was out in the real world and it was just crazy to believe that I'd just had a major surgery and now I'm back at my house. It took a week.
Looking at life before transplant, I really didn't know how long I was really going to be ticking, I think is the best way to put it. The future was very unsure and the knowing that after transplant that I was living off that one segment of the liver, I was like there's no way I was living off that one segment of the liver. I was like, "There's no way I could've kept going. There's no way that I had another three years without things getting really serious."
Host: Jordan's experience as a child living with a chronic condition and then recovering from his transplant surgery have inspired him to become a nurse.
Jordan: From the future now, I've been able to make at least a five-year plan, and even 10, because I can do that now. I have the gift that's allowed me to do that so hopefully, after studying, I would really, really like to get a graduate position, either paediatrics or adults. I'm not really picky personally but I find that being a paediatric nurse, being that was majority of my life in hospital, I'm able to kind of understand what they're going through and able to help the parents in terms of my mom's experience as well. And so, hopefully graduate and all of that and eventually maybe settle down, have a family, but just be able to give back and help other people through their little skits in hospital and just watch them get better and grow.
Host: For Dr Hodgkinson, it's seeing patients like Jordan go on to live full and healthy lives that inspires him.
Dr Hodgkinson: The things that make me get out of bed in the morning and make me most happy is coming to work and seeing a person who's been very sick and you've done an operation or been involved in their treatment and that they've gotten better and gone back to being a normal healthy person.
Host: If you're interested in becoming an organ donor and potentially saving lives of people like Jordan, you can find more information at donatelife.gov.au. We've also linked to Donate Life in our shownotes. Most importantly, Dr Hodgkinson wants people to take time to talk about their desire to be an organ donor with their families after they've signed up.
Dr Hodgkinson: We know that if we ask people, "Would you be happy to be an organ donor?" We actually get quite a high response rate. People say, "Yes, I'd be very happy to." But when it comes to the time of organ donation and we ask people's families, "Would you be happy for your loved one to be a donor?" The people saying yes is a lot lower than what we would expect. And so, it's really important for people out there, if they would be happy to be a donor and help out these people, to actually talk to your family and make a commitment with your family and say, "Yep, look, this is something I would want to do so that when it comes to the time, your family knows what your wishes are."
It really is quite transformative for recipients. If we have a family who says yes to organ donation, often we're having five, six, maybe seven or eight people who have their lives turned back from quite terrible back to normal. And so, it's a very transformative thing. And it's important for everyone out there to consider, could they be an organ donor, and would they like to go through this? And talk to your family about it. That's a really important thing. Let everybody know.
Host: While conditions like Jordan's that affect the liver can't be prevented, there are lots of things you can do every day to keep your liver well and functioning properly. We asked Dr Hodgkinson what the main things are that Queenslander's should be doing to look after their livers.
Dr Hodgkinson: So, the two most important things would be to have a safe amount of alcohol that they drink because we do see quite a lot of people who over the years have drunk a large amount of alcohol and they develop cirrhosis. So, limiting the amount of alcohol you drink to safe levels is really important. The current accepted state safe levels are no more than one to two standard drinks per day and at least a couple of days off each week where you don't have any alcohol. So, that's probably the first thing.
The second thing is, as you pointed out, related to fatty liver disease. And so, it means that we all need to have a very healthy lifestyle in terms of what we eat and how much exercise we do. And treating obesity is really, really important as far as the liver goes. We're seeing a huge increase in people with fatty liver disease. So, we have a huge team of people now who actually help people with fatty liver disease in terms of dieticians, exercise, physiologists, and our transplant hepatologists are all aimed at helping people lost weight to avoid fatty liver disease.
The other important thing to do is to avoid the risky behaviour that might lead to contracting things like hepatitis C. And so, IV drug use and other risky behaviour like that is really important to avoid as well.
Host: And what about detoxing? Should we be drinking any special teas or taking supplements to help our livers out? Dr Hodgkinson says it's a myth that the liver needs any extra help from us in the detoxing department, and products that claim to detox the liver might actually do more harm than good.
Dr Hodgkinson: In fact, the liver actually cleans itself very well. It has an amazing mechanism to clean itself. You don't need to clean your liver. What you need to do is avoiding dirtying up your liver in the first place. So, that's what I was talking about avoiding too much alcohol and keeping a healthy weight and a healthy lifestyle.
So, eating good healthy food and some exercise. And there's a number of medications or natural therapies out there that are marketed as liver detoxification. These things do not detoxify ... Well, I shouldn't say that. These things are not helpful for your liver. You do not need them. In fact, what you need to do is lose weight and drink less alcohol and your liver will take care of itself. And it's an amazing organ. And in fact, some of these liver detoxes, the natural therapies, can actually be dangerous for your liver. And we've had people come with liver failure related to taking a natural therapy which has caused liver damage.
Host: Thanks for joining us for this episode of My Amazing Body. If you enjoyed it, don't forget to leave us a rating or review in your podcast app!
Did you guess this episode's Mystery Body Part? The thin string of tissue that has salvia glands at its base is your frenulum! You can see your frenulum underneath your tongue, connecting it to the bottom of your mouth. Congratulations if you figured it out!
Thank you to Dr Hodgkinson and the team at the Princess Alexandra Hospital and Metro South Hospital and Health Service for lending your time and expertise to this episode. And thanks to Jordan, for sharing your liver transplant story and inspiring us all. My Amazing Body is brought to you by Queensland Health. Thanks to my podcast colleagues, producers Lauren and Jessica, Carol our audio technician and Helen on music and sound effects.