General Information
The Yale Gastrointestinal Pathology Service encompasses the entire
spectrum of diagnostic services on biopsies and resections from the
gastrointestinal tract, liver, biliary tree, and pancreas.
The service,
directed by Marie
Robert, M.D., provides specialized expertise in
the pathologic diagnosis of inflammatory and neoplastic conditions
of the
GI tract. Techniques utilized include routine histopathology, immunohistochemistry,
in situ hybridization, flow cytometry and electron microscopy.
Our
goal is to provide outstanding service to clinicians and patients
through accurate diagnosis, quick turnaround time, and frequent personal
communication.
HIGHLIGHTS
• Four expert gastrointestinal pathologists with specialized
training and ongoing continuous quality improvement activities
• Availability of after hours, weekend, and rush biopsy processing
in appropriate medical circumstances
• Consultation on outside pathologic material
• Ability to develop and utilize new diagnostic tests as
clinically needed
Areas of Expertise
• Inflammatory bowel disease: special expertise in the diagnosis
and management of inflammatory bowel disease, including distinguishing
between Crohn’s disease and ulcerative colitis, and the diagnosis
of dysplasia
•
Barrett’s esophagus: surveillance biopsies to detect dysplasia
in the setting of reflux associated intestinal metaplasia
•
Gastritis: Helicobacter and NSAID related gastric damage; complications
of Helicobacter pylori, such as lymphoma and carcinoma
•
Colonic neoplasia: from polyps to adenocarcinoma, including molecular
studies for genetic predisposition where appropriate
•
Celiac disease and other malabsorptive states
•
Hepatitis C and other forms of chronic liver disease
•
Hemochromatosis
•
Hepatic, pancreatic, and biliary tumors
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About Gastroesophageal Reflux Disease
(GERD)
Heartburn, also called acid reflux or gastroesophageal reflux disease
(GERD), is a burning sensation in the chest that is caused by acid
moving from the stomach into the esophagus. This phenomenon is the
most common gastrointestinal disorder in the United States, with some
studies reporting that 36% of all people experience heartburn at least
once a month. Pregnant women have an especially high rate of heartburn,
48-79%. People with hiatal hernias are also at increased risk of heartburn.
(A hiatal hernia is a common acquired condition where part of the stomach
slides up past the diaphragm into the chest.)
Normally, the regurgitation of acid from the stomach to the esophagus
is prevented by a combination of anatomical structures (such as the
diaphragm and the lower
esophageal sphincter), nervous function, and the proper location of the gastroesophageal
junction in the abdomen. If there is an abnormality in one or more of these “antireflux
barriers,” acid can regurgitate, leading to the sensation of heartburn.
Many people with heartburn have a normal esophagus and can get permanent
relief from their symptoms with a combination of lifestyle changes
and medications
(see below). However, in some people with prolonged acid reflux the lining
of the
esophagus is damaged by the acid. In this setting, the body’s immune
system responds by sending inflammatory cells into the lining of the esophagus.
The
presence of inflammation in the esophageal lining is called reflux esophagitis,
which may lead to ulcers over time and even strictures (narrowing) of the esophagus.
Symptoms include difficulty swallowing or a sensation that food is sticking
to or getting hung up in the esophagus.
Since reflux of acid occurs especially after meals or when lying supine,
it is recommended that people with reflux should permanently elevate
the head
of the
bed, and avoid lying down right after meals. Other recommendations include
avoiding tight fitting clothing, decreasing alcohol, caffeine and cigarette
consumption,
eliminating aggravating foods such as chocolate, and not eating before bedtime.
There are numerous over-the-counter and prescription medications aimed at relieving
heartburn. Most work by decreasing acid production in the stomach (antacids).
Finally, there are surgical procedures to control acid reflux, but these are
rarely necessary. 
While most people experiencing heartburn can be diagnosed and treated without
an endoscopic examination, in some cases a gastroenterologist may need to
look with an endoscope at the esophageal lining. Sometimes a biopsy of the
esophagus
is taken to confirm that there is reflux damage. In addition, some people
with acid reflux injury occurring for many years will have a change in the
esophageal
lining called intestinal metaplasia or Barrett’s esophagus. Biopsies
are frequently performed to look for the presence of intestinal metaplasia,
and if
present, biopsies will be performed at regular intervals in order to detect
precancerous changes so as to prevent the development of cancer of the esophagus.
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Frequently Asked Questions
What determines whether a malignant colon polyp can be treated by
polypectomy alone, or requires surgical resection?
The approach to the therapy of malignant polyps (those exhibiting
submucosal invasion) depends on the evaluation of three histologic
features in
a well-oriented specimen. These are: (1) the margin of excision, measured
from the deepest invasive nest to the cautery mark; (2) the differentiation
of the tumor (well, moderate, or poor); and (3) lymphovascular invasion.
Resection is required when the biopsy margin is positive, when the
tumor is poorly differentiated, and when lymphovascular invasion is
present. Absent any of these three features, polypectomy with additional
follow-up biopsies to ensure that the lesion is completely excised
is adequate therapy.
In inflammatory bowel disease, how does one decide whether a polypoid
dysplastic lesion is a sporadic adenoma or a DALM?
There is no definite method to distinguish between these two entities
with 100% certainty. There are, however, several useful guidelines.
The endoscopic appearance and location of the lesion in relation to
colitis is more important than the histology. Plaque-like lesions with
irregular borders and dysplasia extending to the flat edges are considered
by most clinicians and pathologists to represent DALM lesions. Polyps
that are indistinguishable from sporadic adenomas seen in non-colitic
patients are usually considered “safe” to remove and follow,
even when they occur in areas involved by colitis. However, it should
be understood that pathologists are not able to say with certainty
that even these typical polyps are not DALMs.
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People
Marie E.
Robert, M.D., Associate Professor of Pathology and Attending
Pathologist at YNHH, is a nationally recognized GI pathologist working
at the forefront of national studies on esophageal disorders, inflammatory
bowel disease, and chronic liver disease.
Liming Hao, M.D., Assistant Professor of Pathology, is a specialist
in GI pathology and Attending Pathologist, Bridgeport Hospital. Clinical
interest: gastrointestinal pathology.
Dhanpat Jain,
M.B.B.S., M.D., Assistant Professor of Pathology and Attending
Pathologist at YNHH, is a specialist in GI and liver pathology. Research
interests: liver tumors, gastrointestinal stromal tumors, prostate cancer
risk and mortality, and motility disorders of the bowel.
Zenta Walther,
M.D., Ph.D., Associate Professor of Pathology and Attending
Pathologist at YNHH, is a specialist in GI and liver pathology. Her research
interests include epithelial cell polarity and membrane-associated cytoskeleton.
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