Gastrointestinal pathology

Last updated September 21, 2024

Gastrointestinal pathology is the subspecialty of surgical pathology which deals with the diagnosis and characterization of neoplastic and non-neoplastic diseases of the digestive tract and accessory organs, such as the pancreas and liver.^[1] The gastrointestinal tract is part of the digestive system or alimentary tract, and follows the passage of food and liquids as they pass through the body. The organs included in the gastrointestinal tract include the mouth, the throat (pharynx), esophagus, stomach, small intestine, large intestine, rectum and anus, in that order. ^[2]

Sub-specialty recognition and Board Certification

Gastrointestinal pathology (including liver, gallbladder and pancreas) is a recognized sub-specialty discipline of surgical pathology. Recognition of a sub-specialty is generally related to dedicated fellowship training offered within the subspecialty or, alternatively, to surgical pathologists with a special interest and extensive experience in gastrointestinal pathology. There are approximately 30 gastrointestinal pathology fellowships offered within the United States (predominantly academic, and more recently three "corporate" fellowships). This translates to fewer than 40 fellowship trained gastrointestinal pathologists being trained annually in the United States each year.

Fellowship in gastrointestinal pathology involves:

diagnostic evaluation of surgical (whole organ) and biopsy pathology of gastrointestinal tissue, [with the exception of at least one corporate fellowship]
consistent interaction with clinical colleagues (gastroenterologists, colorectal surgeons and gastrointestinal radiologists) to ensure understanding of the clinical aspects of gastrointestinal disease, treatment modalities and other diagnostic findings;
research in gastrointestinal physiology, disease mechanisms and histomorphology
education of general pathologists and clinical colleagues.

During the course of a one-year gastrointestinal pathology fellowship, the GI-liver pathology fellow will review between 8,000 and 15,000 gastrointestinal and liver biopsy and surgical specimens with all clinical history, laboratory data and frequently, knowledge of response to treatment. This volume of cases is similar to approximately five years of case experience for general surgical pathologists in private practice.

Board certification in the United States requires approval by the certifying body, the American Board of Pathology. There has been considerable debate among academic and private practice gastrointestinal pathologists regarding the necessity, advantages and disadvantages of Board Certification in this subspecialty. The debate was last formally approached in 2001, during Dr. Joel K. Greenson's tenure as President of the Rodger C. Haggitt Gastrointestinal Pathology Society. The decision to seek Board Certification was declined by the membership of the Society.

History of the Rodger C. Haggitt Gastrointestinal Pathology Society

At the 1976 annual meeting of the organization then called the International Academy of Pathology (IAP), now the United States and Canadian Academy of Pathology (USCAP), the long course was devoted to gastrointestinal pathology. Due to its success, the first evening subspecialty conference devoted to gastrointestinal pathology was presented the following year at the IAP annual meeting in March 1977. That first evening session was organized by Jack Yardley from Johns Hopkins University, and included Henry Appelman (University of Michigan), Harvey Goldman (Beth Israel Hospital and Harvard Medical School), Bill Hawk (The Cleveland Clinic), Tom Kent (University of Iowa), Si-Chun Ming (Temple University), Tom Norris (University of Washington), and Robert Riddell (University of Chicago). This group, headed by Henry Appelman, organized a group for gastrointestinal pathologists.

Every gastrointestinal pathologist in the United States and Canada received an invitation to attend the first organizational meeting, held during the 1979 IAP meeting. At that meeting, the establishment of a society was approved, and four subcommittees were formed to deal with membership, finances, bylaws, and educational activities. During the next year, all organizational functions were completed, and at the 1980 IAP meeting, the organization was officially established, by-laws were approved, the first officers elected, the first dues collected, and the first educational program was offered. The original name for the organization was the Gastrointestinal Pathology Club. Only later did it achieve "Society" status. In 2001, after the tragic and untimely homicidal^[3] death of Dr. Rodger C. Haggitt, the name of the society was officially changed to Rodger C. Haggitt Gastrointestinal Pathology Society.

The organization was developed as a mechanism:

for propagating interest in gastrointestinal pathology
for emphasizing the importance of gastrointestinal pathology as a sophisticated and complex area of pathology
for sharing information among members
for developing joint investigative efforts among members
for establishing referral centers or referral mechanisms for specific types of case problems
for devising a registry for unusual cases.

The first three of these initial goals were accomplished early on. The club was recognized as a companion society of the IAP and its first scientific session was presented about a year later. The fourth goal took longer, but it, too, has been fulfilled as exemplified by a published study on adenomas with invasive carcinoma that was shepherded by Harry Cooper. It took e-mail technology to really allow the fifth goal, the referral network, to operate. The development of an e-mail group from the Society, which became an opportunity for members to consult a wide group of GI colleagues regarding problem cases, has been functional since 1995. The sixth goal, the registry issue, has yet to get off the ground. Currently, the Society awards prizes for resident presentations at the USCAP annual meeting and organizes educational symposia at national meetings, including the IAP, the American Society of Clinical Pathologists, Digestive Disease Week and the international congresses of the International Academy of Pathology.

Current Impact of Gastrointestinal Pathology as a Sub-Specialty

Digestive diseases affect 1 in 5 Americans annually – at least 60 million people in the United States each year. Digestive diseases account for approximately 50 million physician visits, nearly 25 million endoscopic diagnostic procedures and over 20 million gastrointestinal specimens directed to pathologists – representing $87 billion in direct medical costs attributable to gastrointestinal disease. The demand for gastroenterology care and diagnostic procedures continue to increase, driven by an increasing incidence of gastrointestinal disease and the need for colorectal cancer screening in the aging U.S. population. By 2010, gastroenterologists will perform at least 40 million endoscopic procedures annually, translating into $40 billion endoscopy and $12 billion related gastrointestinal pathology expenses annually in the U.S.

With less than 400 fellowship-trained gastrointestinal pathologists in practice in the United States, approximately 8% of the 20+ million gastrointestinal biopsies currently performed each year are reviewed by pathologists with fellowship training in digestive health and disease. The remaining 90 to 92% of biopsies are reviewed by highly skilled general surgical pathologists including some who have special interest in gastrointestinal pathology.

General surgical pathologists who practice with a focus in gastrointestinal pathology may attend continuing medical education courses offered by fellowship-trained academic and private practice gastrointestinal pathologists, may attend intensive "mini-fellowships" that are offered by select institutions (i.e. AFIP) to further hone their diagnostic skills and develop close working relationships with gastroenterologists to ensure a broad knowledge base with regards to clinical correlation of the findings under the microscope.

Whether a fellowship trained gastrointestinal pathologist, a general surgical pathologist with subspecialty interest in GI or an adept general surgical pathologist is reviewing a particular biopsy or surgical specimen, it is important to keep in mind that the training for the specialty of surgical pathology is rigorous. Following completion of both college and medical school, the surgical pathologist must have also completed an accredited residency in pathology and is board certified in Anatomic Pathology by the American Board of Pathology. Residency in pathology is one of the longest postgraduate training programs, encompassing 4–5 years. (In comparison, internal medicine and pediatrics are only 3 years.)

In most instances, gastrointestinal biopsies and surgical specimens represent common diseases that display common histomorphologic patterns, and are accurately evaluated and classified by adept general pathologists. Similar to many aspects of medicine, not all gastrointestinal tissue specimens require sub-specialist review for the accurate diagnosis to be rendered. Internal medicine physicians treat many gastrointestinal conditions without referral to a gastroenterologist specialist. Similarly, many gastrointestinal tissue biopsies and surgical specimens are accurately diagnosed without referral to a gastrointestinal pathologist. Certain diseases are histologically subtle or the differential diagnosis is complicated or complex. In such cases a close working relationship between the pathologist and gastroenterologist with correlation of clinical, endoscopic, and biopsy findings may be of great benefit to the submitting physician and to the patient.

Appropriate biopsy classification of GI biopsies is critical. Current literature and other non-published reviews estimate that at least 10% of the diagnoses of Barrett's esophagus, a precancerous condition, are rendered in error. At least 15 – 20% of stomach biopsies have misclassified disease characteristics, 15% of colon polyps are misdiagnosed, and up to 50% of all cases of chronic inflammatory bowel disease are misdiagnosed or misclassified.

Though pathology diagnosis is a critical determinant of future cancer risk and screening interval, many of these diagnoses do not result in significant morbidity or mortality for patients; thus, errors may be "masked" by the limited effect to the patient in the present context.

The economic cost of inaccurate pathology diagnoses can be measured from the perspective of the healthcare system, the gastroenterologist practice and the patient. Within the healthcare system, gastroenterology pathology diagnostic inaccuracy of 10% is equivalent to 2 million misdiagnoses each year. The vast majority of these patients will incur additional medical expenses from repeat clinician office visits; repeat diagnostic procedures, unnecessary enrollment in surveillance programs, and treatment with incorrect or completely unnecessary medications. The cost savings of the correct gastrointestinal pathology diagnosis being rendered at first opportunity by expert board certified surgical pathologists is conservatively estimated within the range of $200M – $1B.

Born out of increasing awareness of subspecialty gastrointestinal pathology services, increased marketing efforts by gastrointestinal pathology companies and increased patient awareness of laboratory errors, there is an increasing trend toward referral of tissue specimens to surgical pathologists with special interest in gastrointestinal pathology.

Related Research Articles

<span class="mw-page-title-main">General surgery</span> Medical specialty

General surgery is a surgical specialty that focuses on alimentary canal and abdominal contents including the esophagus, stomach, small intestine, large intestine, liver, pancreas, gallbladder, appendix and bile ducts, and often the thyroid gland. General surgeons also deal with diseases involving the skin, breast, soft tissue, trauma, peripheral artery disease and hernias and perform endoscopic as such as gastroscopy, colonoscopy and laparoscopic procedures.

Gastroenterology is the branch of medicine focused on the digestive system and its disorders. The digestive system consists of the gastrointestinal tract, sometimes referred to as the GI tract, which includes the esophagus, stomach, small intestine and large intestine as well as the accessory organs of digestion which include the pancreas, gallbladder, and liver.

Pathology is the study of disease and injury. The word pathology also refers to the study of disease in general, incorporating a wide range of biology research fields and medical practices. However, when used in the context of modern medical treatment, the term is often used in a narrower fashion to refer to processes and tests that fall within the contemporary medical field of "general pathology", an area that includes a number of distinct but inter-related medical specialties that diagnose disease, mostly through analysis of tissue and human cell samples. Idiomatically, "a pathology" may also refer to the predicted or actual progression of particular diseases. The suffix pathy is sometimes used to indicate a state of disease in cases of both physical ailment and psychological conditions. A physician practicing pathology is called a pathologist.

Anatomical pathology (Commonwealth) or anatomic pathology (U.S.) is a medical specialty that is concerned with the diagnosis of disease based on the macroscopic, microscopic, biochemical, immunologic and molecular examination of organs and tissues. Over the 20th century, surgical pathology has evolved tremendously: from historical examination of whole bodies (autopsy) to a more modernized practice, centered on the diagnosis and prognosis of cancer to guide treatment decision-making in oncology. Its modern founder was the Italian scientist Giovanni Battista Morgagni from Forlì.

Cytopathology is a branch of pathology that studies and diagnoses diseases on the cellular level. The discipline was founded by George Nicolas Papanicolaou in 1928. Cytopathology is generally used on samples of free cells or tissue fragments, in contrast to histopathology, which studies whole tissues. Cytopathology is frequently, less precisely, called "cytology", which means "the study of cells".

Barrett's esophagus is a condition in which there is an abnormal (metaplastic) change in the mucosal cells lining the lower portion of the esophagus, from stratified squamous epithelium to simple columnar epithelium with interspersed goblet cells that are normally present only in the small intestine and large intestine. This change is considered to be a premalignant condition because of its potential to further transition to esophageal adenocarcinoma, an often-deadly cancer.

A biopsy is a medical test commonly performed by a surgeon, an interventional radiologist, or an interventional cardiologist. The process involves the extraction of sample cells or tissues for examination to determine the presence or extent of a disease. The tissue is then fixed, dehydrated, embedded, sectioned, stained and mounted before it is generally examined under a microscope by a pathologist; it may also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. An incisional biopsy or core biopsy samples a portion of the abnormal tissue without attempting to remove the entire lesion or tumor. When a sample of tissue or fluid is removed with a needle in such a way that cells are removed without preserving the histological architecture of the tissue cells, the procedure is called a needle aspiration biopsy. Biopsies are most commonly performed for insight into possible cancerous or inflammatory conditions.

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems. It is primarily performed by highly skilled and specialty trained gastroenterologists. Through the endoscope, the physician can see the inside of the stomach and duodenum, and inject a contrast medium into the ducts in the biliary tree and pancreas so they can be seen on radiographs.

Dermatopathology is a joint subspecialty of dermatology and pathology or surgical pathology that focuses on the study of cutaneous diseases at a microscopic and molecular level. It also encompasses analyses of the potential causes of skin diseases at a basic level. Dermatopathologists work in close association with clinical dermatologists, with many possessing further clinical training in dermatology. The field was founded by German dermatologist and physician Gustav Simon, who published the first textbook on dermatopathology, 'Skin Diseases Illustrated by Anatomical Investigations', in 1848.

<span class="mw-page-title-main">Pseudomyxoma peritonei</span> Medical condition

Pseudomyxoma peritonei (PMP) is a clinical condition caused by cancerous cells that produce abundant mucin or gelatinous ascites. The tumors cause fibrosis of tissues and impede digestion or organ function, and if left untreated, the tumors and mucin they produce will fill the abdominal cavity. This will result in compression of organs and will destroy the function of the colon, small intestine, stomach, or other organs. Prognosis with treatment in many cases is optimistic, but the disease is lethal if untreated, with death occurring via cachexia, bowel obstruction, or other types of complications.

Fine-needle aspiration (FNA) is a diagnostic procedure used to investigate lumps or masses. In this technique, a thin, hollow needle is inserted into the mass for sampling of cells that, after being stained, are examined under a microscope (biopsy). The sampling and biopsy considered together are called fine-needle aspiration biopsy (FNAB) or fine-needle aspiration cytology (FNAC). Fine-needle aspiration biopsies are very safe minor surgical procedures. Often, a major surgical biopsy can be avoided by performing a needle aspiration biopsy instead, eliminating the need for hospitalization. In 1981, the first fine-needle aspiration biopsy in the United States was done at Maimonides Medical Center. Today, this procedure is widely used in the diagnosis of cancer and inflammatory conditions. Fine needle aspiration is generally considered a safe procedure. Complications are infrequent.

Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron deficiency anemia. The condition is associated with dilated small blood vessels in the gastric antrum, which is a distal part of the stomach. The dilated vessels result in intestinal bleeding. It is also called watermelon stomach because streaky long red areas that are present in the stomach may resemble the markings on watermelon.

Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used to visualize the walls of these organs, or to look at adjacent structures. Combined with Doppler imaging, nearby blood vessels can also be evaluated.

Gynecologic pathology is the medical pathology subspecialty dealing with the study and diagnosis of disease involving the female genital tract. A physician who practices gynecologic pathology is a gynecologic pathologist. The term originates from the Greek gyno-(gynaikos) meaning "woman" and the suffix -ology, meaning "study of".

<span class="mw-page-title-main">Surgical pathology</span> Area of practice for anatomical pathologists

Surgical pathology is the most significant and time-consuming area of practice for most anatomical pathologists. Surgical pathology involves gross and microscopic examination of surgical specimens, as well as biopsies submitted by surgeons and non-surgeons such as general internists, medical subspecialists, dermatologists, and interventional radiologists.

Pulmonary pathology is the subspecialty of surgical pathology which deals with the diagnosis and characterization of neoplastic and non-neoplastic diseases of the lungs and thoracic pleura. It is the study of diseases affecting the lungs and respiratory system. Diagnostic specimens are often obtained via bronchoscopic transbronchial biopsy, CT-guided percutaneous biopsy, or video-assisted thoracic surgery (VATS). The diagnosis of inflammatory or fibrotic diseases of the lungs is considered by many pathologists to be particularly challenging.

<span class="mw-page-title-main">Capsule endoscopy</span> Medical imaging procedure

Capsule endoscopy is a medical procedure used to record internal images of the gastrointestinal tract for use in disease diagnosis. Newer developments are also able to take biopsies and release medication at specific locations of the entire gastrointestinal tract. Unlike the more widely used endoscope, capsule endoscopy provides the ability to see the middle portion of the small intestine. It can be applied to the detection of various gastrointestinal cancers, digestive diseases, ulcers, unexplained bleedings, and general abdominal pains. After a patient swallows the capsule, it passes along the gastrointestinal tract, taking a number of images per second which are transmitted wirelessly to an array of receivers connected to a portable recording device carried by the patient. General advantages of capsule endoscopy over standard endoscopy include the minimally invasive procedure setup, ability to visualize more of the gastrointestinal tract, and lower cost of the procedure.

Pediatric gastroenterology developed as a sub-specialty of pediatrics and gastroenterology. It is concerned with treating the gastrointestinal tract, liver and pancreas of children from infancy until age eighteen. The principal diseases it is concerned with are acute diarrhea, persistent vomiting, gastritis, and problems with the development of the gastric tract.

Confocal endoscopy, or confocal laser endomicroscopy (CLE), is a modern imaging technique that allows the examination of real-time microscopic and histological features inside the body. In the word "endomicroscopy", endo- means "within" and -skopein means "to view or observe". CLE, also known as "optical biopsy", can analyse histology and cytology features of a tissue which otherwise is only possible by tissue biopsy. Similar to confocal microscopy, the laser in CLE filtered by the pinhole excites the fluorescent dye through a beam splitter and objective lens. The fluorescent emission then follows similar paths into the detector. A pinhole is used to select emissions from the desired focal plane. Two categories of CLE exist, namely probe-based (pCLE) and the less common endoscopy-based endoscopy (eCLE).

References

↑ "Gastrointestinal Pathology". Pathology Laboratory Associates. Retrieved 2024-09-20.
↑ "https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract". www.cancer.gov. 2011-02-02. Retrieved 2024-09-20.{{cite web}}: External link in |title= (help)
↑ Olympia Washington newspaper, Morning Olympian, 29 June 2000, page 19 and 1 November 2000, page 19

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[1] "Gastrointestinal Pathology". Pathology Laboratory Associates. Retrieved 2024-09-20.

[2] "https://www.cancer.gov/publications/dictionaries/cancer-terms/def/gastrointestinal-tract". www.cancer.gov. 2011-02-02. Retrieved 2024-09-20.{{cite web}}: External link in |title= (help)

[3] Olympia Washington newspaper, Morning Olympian, 29 June 2000, page 19 and 1 November 2000, page 19

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