About the Program
Next opening: 2027-2028
Number of positions: 1
Length: 1 year
This ACGME-accredited fellowship provides robust training in disorders of the luminal GI tract, pancreas and hepatic pathology (medical liver including liver transplantation), preparing trainees for a career in an academic or private practice setting. Five GI pathologists provide clinical service, contribute to the research program of the GI section, and support the GI Pathology training program across four distinct hospital and outpatient settings.
The GI pathology fellow will get exposure to a comprehensive spectrum of gastrointestinal surgical specimens, ranging from small biopsies to complex procedures, as well as hepatobiliary specimens. Training also includes reviewing consult digital slides from community practices in Texas. The fellow will have graduated responsibility in performing operating room consultations (frozen sections and gross examination). The fellow is expected to closely interact with surgeons/clinicians and pathology colleagues from community practice, actively participate in tumor boards, IBD/liver conferences, participate in research projects and will have the opportunity to attend and contribute to numerous didactic and clinical conferences.
Rotations
The fellow will rotate across two institutions: Baylor St. Luke’s Medical Center and Texas Children’s Hospital, with a one-month rotation at MD Anderson Cancer Center. Program strengths include extensive experience in routine and complex gastrointestinal pathology, pancreatic pathology, medical liver biopsies, liver transplantation, and pediatric pathology.
A one-week rotation in clinical gastroenterology is included, during which the fellow may observe advanced endoscopic procedures such as EMR/ESD and EUS-guided FNA/FNB performed by experienced gastroenterologists.
Stipends and Benefits
Visit the Graduate School of Biomedical Sciences page on stipends and benefits for fellows.
Admissions
Candidates must be board certified or eligible for certification in anatomic pathology or AP/CP.
All application materials, including recommendation letters, must be submitted online, and include the following:
- Completed online House Staff Application
- Current Curriculum Vitae
- Personal Statement
- Transcript from Medical School(s)
- Three Recommendation Letters
Applications are accepted from mid-April to July 31 for positions beginning July 1 two years later. Interviews are conducted starting in July or August and are completed by the end of August of the application year.
Case of the Month
Dorsay Sadeghian, M.D., PGY3
Shilpa Jain, M.D., Associate Professor
A 50-year-old patient presented with high alkaline phosphatase with normal bilirubin, AST and ALT (cholestatic pattern). Liver biopsy shows concentric fibrosis around affected bile ducts with onion-skin appearance resembling primary sclerosing cholangitis (PSC). Granulomatous vasculitis of hepatic vessels is also noted.
Which feature most strongly supports ischemic cholangiopathy secondary to granulomatous vasculitis rather than primary sclerosing cholangitis?
A. Presence of biliary strictures on imaging
B. Chronic cholestatic laboratory pattern
C. Association with inflammatory bowel disease
D. Presence of vasculitis and reversibility with immunosuppressive therapy
E. Onion skin periductal fibrosis on histology
Correct Answer: D. Potential reversibility with immunosuppressive therapy
The presence of biliary strictures on imaging can result from a variety of causes. Although rare, ischemic cholangiopathy and vasculitis may lead to strictures. More commonly, etiologies include:
- Malignancies: cholangiocarcinoma, pancreatic, gallbladder, or ampullary adenocarcinoma
- Benign inflammatory or autoimmune causes: primary sclerosing cholangitis (PSC), IgG4-related sclerosing cholangitis
- Latrogenic or traumatic causes: prior surgery, instrumentation, or radiation
- Infectious causes: parasitic infections, recurrent pyogenic cholangitis
Chronic cholestatic laboratory patterns are defined below and can be seen in a wide variety of clinical conditions.
- Alkaline phosphatase (ALP): markedly elevated (typically ≥2 - 3× upper limit of normal)
- Gamma-glutamyl transferase (GGT): elevated (supports hepatic origin of ALP)
- Bilirubin: may be elevated, mainly direct (conjugated)
- AST and ALT: normal or only mildly elevated (usually <2 - 3× ULN)
Primary sclerosing cholangitis (PSC) has a well-established association with inflammatory bowel disease (IBD), particularly ulcerative colitis (UC). Approximately 60–80% of patients with PSC have coexisted with UC. However, only 2–7% of patients with UC develop PSC, reflecting the overall rarity of this condition.
The patient’s symptom improvement marked alkaline phosphatase reduction, and resolution of vasculitis on liver biopsy after treatment support ischemic cholangiopathy secondary to granulomatous vasculitis. The differential for hepatic granulomatous vasculitis is broad, including systemic vasculitis (e.g., granulomatosis with polyangiitis, polyarteritis nodosa), immune-mediated conditions (e.g., sarcoidosis), and infections (e.g., mycobacterial or fungal). In this case, the absence of infectious organisms, lack of systemic vasculitis features, localized vascular involvement, and negative serologies favor a primary granulomatous vasculitis confined to the liver.
Presence of onion-skin, concentric fibrosis can be seen either primarily in PSC or secondary to various conditions, including but not limited to long-standing stricture, vascular and ischemic injuries and recurrent cholangitis.
Summary: Granulomatous vasculitis of the liver is rare and a diagnostic challenge, due to its broad differential and risk of ischemic injury. Ischemic cholangiopathy typically arises from hepatic artery thrombosis, prolonged hypotension, or post-transplant complications, presenting acutely with bile duct necrosis. Any disruption of hepatic blood flow—such as granulomatous vasculitis of medium-sized arteries—can cause similar injury. Chronic or indolent vascular compromise may mimic histologic features of primary sclerosing cholangitis (PSC), but unlike PSC, these changes may be reversible with immunosuppressive therapy. In this case, long-term infliximab treatment led to a marked reduction in alkaline phosphatase and improvement of liver biopsy.