GI & Liver Attachments

There are normally up 1-2 trainees on GI and 1-2 on liver attachment. On average, year 1 trainees have 3 weeks GI, and year 2-5 trainees have one or two longer attachment in GI and one attachment in liver – during this you will only be called upon to help with the GI cut up during unusually busy periods.

Consultants

Alison Cairns	(4 days, not Fridays; GI + pancreas)
Caroline Verbeke	(GI + Pancreas)
Darren Treanor	(3 days, Monday, Thursday, Friday; GI biopsies + Liver)
Judy Wyatt	(GI biopsies + Liver)
Nigel Scott	(GI)
Olorunda Rotimi	(GI + Liver)
Heike Grabsche	(Tuesdays and Fridays; GI)
Padmini Prasad	(GI + renal)

Regular Meetings

Monday -	9.15am – colorectal MDT, at LGI
	11.00am - Liver Multiheader Session
	12.30pm – 2.00pm = Liver CPC + Lunch and Postgraduate Meeting
Tuesday -	8.30 upper GI MDT, level 07 Bexley
	14.00 - GI Multiheader session (alternate weeks, red on GI rota)
Wednesday -	Postgraduate Teaching Level 7 2-5pm
Afternoons Term Time
Thursday -	8am - Pancreatic MDT Meeting
	14.00 GI Multiheader session (alternate weeks, red on GI rota)
Friday	8.00 Hepatobiliary MDT Meeting

	15.00 paediatric liver &GI CPC

GI and Pancreas attachments

Cut-Up Rota

Produced by Caroline Verbeke, copy on Notice board near her office. Trainees are attached to 2-3 Consultants – as indicated on the rota, and normally do the cut up with these consultants. Check the previous afternoon what there is for cut-up

Cut ups:

Trainee(s) meet with the consultant for the day in Cut up at 09.00 to agree how cut up cases will be distributed/supervised. Ensure your full name (not initials) plus consultant’s name is on request form of all cases you cut up. When cases come out of the lab, make sure you see the slides. View the slides and draft a report promptly, ready to check the same/next day.

Biopsies:

Trainees who have passed part 1 MRCPath start working independently, according to the departmental protocol (attached). You will be given cases by the consultant you are working with. Check biopsies with the consultant assigned to the case unless they are away.

Recommended reading:

Before attachment – be familiar with departmental SOP’s for specimen dissection in GI cases, and college minimum data sets. Read Dr Verbeke’s notes on pancreatic specimens (available on Deanery histopathology trainee website).
Print yourself a set of RCPath dataset documents from the college website, put them in a folder, and refer to them when you report these resection specimens. Keep an example of a report of each resection specimen type (with photos) in your portfolio. Familiarity with these forms an important part of the final MRCPath exam.
During the first week – read relevant chapters on GI pathology in standard textbooks (e.g. Ackerman, Sternberg) and biopsy pathology book (e.g. ‘Day and Dixon’ for upper GI tract). Year 1 trainees should know the contents of the GI chapters in Molavi: The Practice of Surgical Pathology.
Specific reading about uncommon histopathology cases encountered during reporting.

Educational targets for this specialty:

GI biopsies: report 5 biopsies per day, initially checked by consultant. Post part 1 MRCPath start working towards level 1-2 independent reporting.

GI resections: cut up and report at least one of each major GI resection during each attachment. Be familiar with the RCPath datasets. Post part 1 trainees, collect appendix and gall bladder towards independent reporting.

Main Liver Attachment

Trainees work with Consultants in specialist Liver Pathology – Wyatt, Treanor, Rotimi. They will see all of the liver biopsies and resection specimens, and have this opportunity for at least two weeks to study Liver Pathology in depth. There should be time to work independently through the materials listed below, in addition to reporting the liver specimens.

There is a set of training materials to support this attachment:

Introductory note on liver biopsies.
Departmental guidelines reporting common liver diseases.
CD-Rom by Prof. Scheuer – now on liver pages website
Article on liver pattern recognition by Dr. Bateman.
Introductory slide set with commentary.
Good examples, with comments.
Previous Liver EQA scheme circulations.

RCPath Data Set Documents

Liver resection with primary and metastatic carcinoma.

Tissue Pathways

Liver biopsies.

Recommended Reading

Liver Biopsy Interpretation, Scheuer + Lefkovitch, edition 2006.

Objectives

By the end of attachment, trainees should be able to:

Systematically analyse and formulate a report on straight-forward medical liver biopsies to standard required for MRCPath.
Orientate, cut up and formulate a report on liver resection specimens for metastatic colorectal cancer and explants specimens.

Opportunities for Independent Reporting in Liver Histology

All reporting is Consultant supervised.

Opportunities for Presenting Cases in CPC

Trainee should be given the opportunity to present at least one case at the CPC during this attachment.

Multiheader Teaching Sessions

Mondays 11.00am-12.30pm – Intended for trainees on GI and Liver attachments, and any other trainees wishing to refresh liver experience.

Independent reporting in GI pathology:

Basic level:

Post part 1 MRCPath: collect 20 cases from this list, including at least 2 of each specimen type (RCPath levels 1&2):

Appendix

Normal
Acute appendicitis
Enterobius infestation (excluding granulomatous appendicitis, serosal inflammation without mucosal inflammation, tumours)

Gallbladder

Normal
Chronic/acute cholecystitis, Cholelithiasis

GI Biopsies

Normal mucosal biopsies (oesophagus, stomach, duodenum, large bowel)
Haemorrhoids

Once confident at reporting these independently, start collecting 20 cases from the level 3 list:

Level 3

Oesophageal biopsies

Acute/chronic inflammation (excluding cases of immuno-compromise and Barrett’s oesophagus)

Gastric biopsies

Bacterial/non-bacterial gastritis (excluding eosinophilic or granulomatous gastritis)
Intestinal metaplasia
Fundic glandular cysts

Colonic biopsies

Metaplastic polyp

Adenomas

Anal skin tags (non-viral/AIN)

Colonic/ileal resections

Diverticular disease
Acute ischaemia/infarction
Sigmoid volvulus
Colostomy/ileostomy closure
Meckel’s diverticulum

Liver biopsies

Level 4 cases can be reported independently by trainees who have passed the final MRCPath exam:

Level 4

Oesophageal biopsies

Barrett’s oesophagus (excluding dysplasia)

Colonic biopsies

Confirmation of IBD in patients with known history (excluding dysplasia)
Oesophagectomy for cancer – according to protocol
Gastrectomy for cancer – according to protocol

Colectomy

for cancer – according to protocol
for known inflammatory bowel disease

Specific exceptions

All primary diagnoses of malignancy are to be reported only under supervision

Evaluation of competence for independent reporting of GI histopathology form (here)