The GI and Liver Pathology Program: A view through the ages

Cushing Medical Library

Cushing Medical Library

Gastrointestinal and liver pathology at Yale has a very interesting evolution, which is tied is some way to the evolution of Gastroenterology and Hepatology at Yale. In the first half of the 20th century, Gastrointestinal Pathology was a branch of surgical pathology and mainly concerned with tumors and peptic ulcers. Two things facilitated a shift in emphasis to more medical pathology: the development of flexible endoscopes that allowed access to much of the upper and lower intestinal tracts, and the fact that most intestinal diseases arise in the mucosa, and therefore can be biopsied via endoscopes. A third factor was that the mucosal biopsies obtained endoscopically were necessarily small, and many anatomic pathologists accustomed to working with resection specimens and autopsies were reluctant to hazard a diagnosis on such tiny fragments of tissue. 

 Avery Liebow
Chair of Pathology 1935-1937

For example, Averil Liebow, director of anatomic pathology at Yale (and a distinguished leader in the field of pulmonary pathology), refused to accept biopsies from Howard Spiro, the chief of clinical gastroenterology, who consequently set up his own histology laboratory, and taught himself (and his clinical fellows) to read GI biopsies. Gerald Klatskin, the chief of Hepatology, may have met with the same refusal of Liebow when it came to interpreting needle biopsies of liver for he, too, set up his own histology lab and not only read all his own liver biopsies (as his fellows also were trained to do), but became one of the great interpreters of liver morphology of his time.

Gerald Klatskin
Gerald Klatskin, first liver biopsy 1945

In the 1970s and 1980s as endoscopic biopsies of the gastrointestinal tract and core biopsies of liver became part of the work-up for many diseases, endoscopists and hepatologists were too busy to spend time reading biopsies, and were happy to hand over this responsibility to pathologists. Books on such biopsies were published, e.g. Richard Whitehead’s  “Mucosal Biopsy of the Gastrointestinal Tract” (Saunders, 1973) and Peter Scheuer’s “Liver Biopsy Interpretation” (Saunders, 1968), and pathology departments geared up to handle the avalanche of gastrointestinal and liver biopsies that was to hit them. With the growth in number of submitted cases (now often 25 – 30 % of total pathology work-load), sub-specialization became inevitable. An added complication of these ‘medical’ biopsies is that many of the biopsy diagnoses require a discussion with the submitting clinicians, either to obtain more clinical information to fine tune the diagnosis, or to ensure that the clinicians fully understand the implications of the pathologist’s diagnosis for further work-up and management of their patient. 

Ken Barwick
Ken Barwick Yale Pathology 

In many of the larger pathology departments GI and Liver pathology became a sub-specialty, as had other high-volume (e.g. dermatopathology) or technically specialized (e.g. renal pathology, hematopathology) disciplines. In some departments sub-specialization was complete, but probably more often it took the form of a generalist surgical pathologist with a special interest in a certain area. This was the situation at Yale in the late seventies when Daniel G (Gerry) Sheahan was the principal GI pathologist, but took his share of rotations on the general surgical pathology service. When Sheahan left to take a position in Dublin, Ken Barwick took responsibility for gastrointestinal pathology. Spiro’s laboratory had closed, but Klatskin still had his laboratory and read liver biopsies, but by 1986 both histology laboratories had been integrated into the surgical pathology histology laboratory. 

A. Brain West
Director, Yale Anatomic Pathology 2008-2015

In 1985, Vince Marchesi, the chairman of the Yale Department of Pathology, obtained funding to support a fellow in gastrointestinal and liver pathology under the direction of Ken Barwick. Brian West joined the department as Ken’s fellow in July 1986 and split his time between Mark Mooseker’s lab in Biology (working on cytoskeleton of the intestinal brush border) and the clinical service. A year later Barwick went on sabbatical leave and West took his position on the general surgical pathology service, with special responsibility for gastrointestinal and liver pathology. When Barwick decided not to return, West was appointed to his former position. In the next few years he sub-specialized the gastrointestinal and liver Pathology service completely, and ran it with the help of one fellow. The pathology service grew (from abut 8,000 cases in 1990 to some 50,000 annually at present), and sometimes had the relief of a second fellow. 

The fellowship program has continued throughout the years, usually with one but some times with two fellows. In 1986 there was only one other such fellowship program as far as we are aware, Jack Yardley’s fellowship in Johns Hopkins University. This was a 2-year program, with positions for 2 fellows; thus there was always one first-year and one second-year fellow, and the second-year was expected to act as a junior attending and sign out her or his cases. There are now approximately 20 GI pathology programs in the United States. 

In the early 1990s, faculty and fellows laid the foundation for the formal gastrointestinal and liver fellowship program at Yale and developed the medical school curriculum in gastrointestinal and liver pathology that has been modified over the years. Brian West left Yale in 1995 only to return in 2008 as the director of anatomic pathology, a position from which he retired in 2015. Over the years prominent gastrointestinal and liver pathologists have served as the directors of the program, including James Crawford and Marie Robert. Since it was started the Yale gastrointestinal and liver pathology program has enjoyed national and international recognition for it clinical expertise, research and training program. The pathology program is intimately associated not only with the section of digestive diseases and liver center at Yale, but also works closely with the Smilow cancer center and transplant program. The GI and liver pathology at Bridgeport and St. Raphael campuses are now also integrated with the main campus at Yale. Annually the program handles approximately 20,000 gastrointestinal and liver biopsies, 15,000 surgical resections and 50 liver transplants including the Bridgeport and St. Raphael campuses. The program now has two ACMGE accredited fellowship positions and includes clinical and research fellowship tracks. Currently the program has 7 faculty members including Brian West, Marie Robert, Xuchen Zhang, Joanna Gibson, Liming Hao and Andrea Barbieri, and is directed by Dr. Dhanpat Jain.

pathology GI group having fun at photo shoot
Photo by Kate Henderson

GI and Liver Team:

(left -right) Andrea Barbieri, Romulo Celli, Marie Robert,  ILKe Nalbantoglu, Joanna Gibson, Dhanpat Jain (Director), Xuchen Zhang, not shown Liming Hao.