Departments

We provide expert, compassionate inpatient and outpatient care for children with a variety of gastrointestinal, liver, and metabolic disorders including inflammatory bowel disease, esophageal disorders, diarrheal disease, acute and chronic liver disease, and metabolic liver diseases, including lysosomal diseases. Our care team harnesses the expertise of gastrointestinal nursing, nutrition, radiology, surgery and genetics experts, as well as Yale’s programs in inflammatory bowel disease and liver transplantation. Our multidisciplinary approach for our patients with nonalcoholic fatty liver disease also includes a clinical psychologist, a dietician, and an endocrinologist.The program also offers selective shunts for patients with noncirrhotic portal hypertension. Gastrointestinal conditions we often manage include: Abdominal Pain Celiac disease Constipation/Encopresis Eosinophilic esophagitis/allergic bowel disease Failure to thrive Feeding problems/swallowing problems Helicobacter pylori infection Hirschsprung’s disease Lactose intolerance Malabsorption Pancreatitis Peptic ulcer disease Vomiting Our pediatric hepatologists treat a range of liver diseases. Some can be managed with medication, while others require surgery. For example,acute liver failure(ALF) occurs when many of the cells in the liver die or become very damaged in a short period of time. ALF has many causes, such as metabolic conditions or toxicity from incorrect dosages of acetaminophen.ALF can sometimes be treated with medication, if it is identified early, but about half of all children who develop ALF require a liver transplant. Biliary atresiais a disease of the liver and bile ducts that occurs in infants. In children with biliary atresia, bile—a liquid that helps the body digest fat—cannot properly drain from the liver. This damages liver cells and can lead to liver failure. Surgical procedures can correct bile flow problems, but the liver disease progresses and requires specialized care to improve growth, development, nutrition, and long-term outcome.A multidisciplinary team consisting of pediatric liver specialists, surgeons, and a dietician provides comprehensive care for patients with biliary atresia. Other hepatology conditions we treat include: Alagille syndrome Alpha-1-antitrypsin deficiency Autoimmune hepatitis Neonatal cholestasis Progressive Familial Intrahepatic Cholestasis (PFIC) Urea cycle defects Wilson's disease Primary Sclerosing Cholangitis Glycogen Storage Disease Viral hepatitis Hepatoblastoma Nonalcoholic fatty liver disease

Our multidisciplinary group of physicians and health providers are committed to providing state-of-the-art therapy to our patients with hepatitis B and hepatitis C infections. We have a 50-year tradition of excellence in liver research and patient care, and continue to be international leaders on the study and treatment of liver disorders. As a partner of the Yale School of Medicine Liver Center, one of only four liver research centers in the country sponsored by the National Institutes of Health, ours is the premier program in Connecticut offering comprehensive patient care for individuals with viral hepatitis. The key to effective disease management of acute and chronic viral hepatitis is our coordinated care among specially trained physicians, as well as a specialized nurse who provides teaching and psychological support. We enjoy close relationships with specialists in adult and pediatric gastroenterology, transplant hepatology, medical and transplant nephrology, transplant surgery, gastrointestinal pathology, diagnostic and interventional radiology, gastrointestinal surgery, rheumatology, OB/GYN, medical and surgical oncology, infectious diseases, the AIDS Care Program, psychiatry, and addiction medicine. The Gastrointestinal Pathology program at Yale is the only subspecialty program of its kind in Connecticut, and provides expert consultative services for the most challenging liver pathology examinations in the region. We partner with Yale New Haven Hospital’s Nathan Smith Clinic in the management of patients with HBV/HIV and HCV/HIV co-infections, and with the Yale Liver Transplant Program in the pre- and post-transplant evaluation and management of patients with liver cirrhosis and end-stage liver disease. We have four areas aimed at improving treatment and outcomes for viral hepatitis: Education: Providing formal education classes and individualized instruction sessions for patients with chronic hepatitis C infection prior to the initiation of antiviral therapy Treatment: Maintaining high standards of practice in treatment protocols and close coordination of care with referring physicians to provide the most advanced and scientifically based approaches to the management of viral hepatitis Research: Ensuring the opportunity for patient access to novel approaches in the treatment of viral hepatitis and liver disorders through clinical trials Community outreach: Building relationships with the surrounding communities of Greater New Haven and Connecticut to raise awareness about viral hepatitis, and to promote screening and education Special services offered by the Yale Viral Hepatitis Program include: Weekly multidisciplinary patient care conferences and liver pathology conferences to draw upon the varied expertise of our Yale Medicine physicians Coordination with the liver and kidney transplant programs Comprehensive services for diagnostic and interventional GI endoscopy, percutaneous and trans-jugular liver biopsy, paracentesis and trans

Our program consists of dedicated experts and support staff committed to providing cutting-edge care to patients with disorders including autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). Other conditions that we treat include sarcoidosis, autoimmune mediated liver injury, cholestasis of unknown etiology, lupus, cholangitis, secondary cholangitis, and overlap syndromes. The program offers effective and personalized treatment for patients with these rare liver diseases. Our doctors are specialists in these conditions, with expertise in interpreting biopsy scans, medications, and more. Patients also have access to our clinical trials, any of which offers new treatment options otherwise unavailable to the general public. We are partnered with the Yale School of Medicine Liver Center, one of only four National Institutes of Health-sponsored liver research centers in the United States, and the only center in Connecticut that offers comprehensive patient care for individuals with autoimmune and cholestatic liver diseases. Our team includes three autoimmune and cholestatic liver disease program experts. Together, they provide care that integrates basic, translational, and clinical research. Our combined expertise allows us to discuss and treat difficult cases from many angles. The research conducted by the program is mainly patient driven and aimed at finding solutions that patients can benefit from. The key to effective therapy is collaboration—we work closely with specialists in adult and pediatric gastroenterology, advanced endoscopy, transplant hepatology, transplant surgery, pathology, diagnostic and interventional radiology, gastrointestinal surgery, rheumatology, endocrinology, and medical and surgical oncology within the Yale Medicine system to provide any additional support that patients may need.

At Yale Medicine, our experts and caregivers give comprehensive and compassionate treatment for those with end-stage liver, kidney, and pancreas organ failure who might benefit from transplantation. We offer many treatment options and hope for high-risk patients who may have been turned down for transplant elsewhere, in addition full support services. Our expert physicians specialize in anesthesiology, internal medicine, pediatrics, surgery, transplant immunology, kidney diseases, liver diseases, diabetes mellitus, and transplant surgery. Our caring, highly skilled nurses, physician assistants, nutritionists, pharmacists, social workers, and financial counselors further support your needs. Many inherited metabolic liver diseases such as Wilson's disease, Gaucher's disease, lipidosis, alpha-1 antitrypsin deficiency, hemochromatosis, tyrosinemia, and glycogen storage diseases are cured by successful liver transplantation. We specialize in genetic testing for liver diseases and treatments that provide comprehensive care for affected patients. Even though we treat some of the most seriously ill patients, our program's survival rates are consistently higher than the national average. We offer many options for advanced liver disease, including living donor and deceased donor transplantation, liver transplantation in HIV-infected individuals, and pre- and post-transplant antiviral therapy to prevent or treat recurrent hepatitis C. Through our acute liver failure program, we can transfer patients to Yale New Haven Hospital in a timely manner for transplant evaluation and medical management. In collaboration with the hospital’s Medical Intensive Care Unit, we offer innovative techniques such as hypothermia therapy for the treatment of acute liver failure. Pancreatic transplants are less common than kidney or liver transplants and are usually performed in patients with type 1 diabetes. Our physicians perform isolated pancreas transplantation, simultaneous kidney/pancreas transplantation, and pancreas transplantation following kidney transplantation. Specialized care is offered in the following areas: Combined organ transplantation including kidney, kidney/liver, and kidney/heart Comprehensive tissue typing and immune evaluation services Follow-up and psychosocial support Leading-edge treatment options for immunosuppression Liver transplantation, including adult-to-adult living donor, pediatric living donor, and other surgeries Minimally invasive living-donor kidney surgeries Robotic hepatobiliary surgery Surgical therapy of diseases of the liver and biliary systems and end-stage kidney and liver disease Telemedicine via patient portal

Our hepatologists, or those who specialize in treating disorders of the liver, gallbladder, and bile ducts, are highly trained and equipped to treat acute or chronic liver disease. Our doctors are able to provide answers to patients with acute or chronic liver disease, from initial evaluation to management of difficult and complex disease. Our special services include: Diagnosis and treatment of complex liver disorders, including cholestasis, autoimmune diseases, and metabolic diseases (such as Wilson's Disease, hemochromatosis, and alpha-1 antitrypsin deficiency) Liver biopsy, large volume paracentesis, infusions, invasive measurement of portal pressure, endoscopic treatment of variceal bleeding, and Transjugular Intrahepatic Portosystemic Shunts (TIPS) Nutrition evaluation and treatment Management of chronic liver disease and cirrhosis Inpatient treatment of decompensated liver cirrhosis and acute liver failure Our primary clinical programs are: The Viral Hepatitis Program provides state-of-the-art therapy for patients with Hepatitis B and Hepatitis C infections. The Steatohepatitis Program specializes in nonalcoholic steatohepatitis (NASH), a liver disease that is related to fatty liver that is becoming more common. It is associated with a number of metabolic disorders, including diabetes and obesity. The Liver Cirrhosis Program periodically monitors patients for the development of cirrhosis, in which scar tissue replaces healthy liver tissue. The Liver Cancer Program features a team of specialists, from transplant surgeons to medical oncologists, who work together to find the best treatment in order to preserve liver function and monitor for possible recurrence of the cancer. The Liver Transplant Program offers comprehensive care to patients who need living or deceased donor transplantation. Liver transplantation is the cure for many acute and chronic liver diseases.

Fatty liver disease is a serious condition caused by stress placed on the liver from excess body weight. People with obesity, diabetes, high blood pressure, and high lipids are at high risk of developing fatty liver disease. Currently, weight loss of 7 to 10% has been shown to be the most effective way of improving fatty liver disease. Patients in our program lose weight safely and effectively through a combination of medications, endoscopic weight loss, bariatric surgery, and therapies. The Yale Medicine Fatty Liver Disease program provides a comprehensive suite of services to help manage the condition. These include: Medications: At Yale, many clinical trials are underway to test the ability of new drugs to treat fatty liver disease. Drugs under development seek to reverse the increased fat in liver cells (and the resulting inflammation and scarring), as well as the increased risk of liver cancer. Medical Weight Loss: Most weight loss medications are tablets that work by reducing appetite. Other medications mimic hormones that the body makes, and improve the body’s ability to manage extra calories. We also offer the OPTIFAST® program, which is a medically monitored weight management program that allows the patient, under the supervision of a physician, to consume a low-calorie diet and receive comprehensive lifestyle education. The typical OPTIFAST patient loses between 30 to 60 pounds in 18 to 24 weeks, and experiences a healthy decrease in blood pressure and cholesterol levels. Additionally, in clinical studies of the OPTIFAST program, about half of the people assessed had maintained enough weight loss for five years to improve their long-term health. Bariatric Surgery: Bariatric surgery is the most effective way to treat fatty liver disease, with improvement in approximately 90% of patients. Bariatric surgery can improve hepatic fibrosis and may reduce the risk of liver cancer. If patients have a body mass index (BMI) above 35, and they have fatty liver disease, they may qualify for bariatric surgery. Patients who are referred to our program will first undergo blood tests and imaging to determine whether or not they have NAFLD (nonalcoholic fatty liver disease) or NASH (nonalcoholic steatohepatitis). Once the diagnosis has been made, we will determine how serious the condition is, which helps our team develop a personalized treatment plan. We take a comprehensive approach to managing fatty liver disease—from medications to bariatric surgery—and refer severe cases to the liver cancer tumor board, if necessary.

Obesity is a common problem that can cause fatigue, diabetes, fatty liver disease, and sleep problems, and raise the risk of many cancers. It reduces energy, and can take the pleasure out of many aspects of life. Extra weight also places stress on vital organs, including the heart, liver, and kidneys, as well as joints and the reproductive system. Although organs can work under this extra stress for a number of years, eventually they are likely to fail. Most organs lose about 80% of their capacity before symptoms are evident, and by that time, it is often too late to return them to normal function. The conditions associated with obesity are: Cancer Cardiovascular disease Diabetes Liver disease Obstructive sleep apnea Losing weight can help improve and sometimes cure many of these conditions, as well as fertility issues. Losing weight can also lead to a life with fewer medications, lower health expenses, and overall greater enjoyment. At the Yale Metabolic Health and Weight Loss Program, we offer all nonsurgical weight-loss interventions in one location. Our philosophy is to focus on health, rather than specific disease, and to tailor our care to each patient’s specific needs and goals. The first step in our care is to determine weight-loss goals. Patients may need to lose 5 to 10% of their body weight to help in the treatment of a disease. We will help patients choose from interventions that include intensive meal-replacement programs, a range of medications, or endoscopic (nonsurgical procedure) options. Sometimes, there are additional medical necessities, such as an upcoming surgery, that require a specific weight-loss goal. We will explain the advantages and disadvantages of the various options, but the choice will depend primarily on what feels right to the patient. We provide therapies under the medical supervision of obesity experts. Patients can choose from the full range of tested interventions: Lifestyle changes: Nutrition counseling goes hand-in-hand with medical management of metabolic health. Care will include a personal visit with a registered dietitian with advanced training in weight management. OPTIFAST® program: OPTIFAST® is a medically monitored weight management program that allows patients, under the supervision of a physician, to consume a low-calorie diet and receive comprehensive lifestyle education. The OPTIFAST program provides full meal replacement for 12 weeks and transitions to self-prepared “everyday” meals in conjunction with comprehensive patient education and support, to help patients achieve long-term weight loss. Medications: All medications are used as part of a comprehensive program that includes proper nutrition and a healthy lifestyle. Contrave® is a single pill that contains two medications (naltrexone and bupropion) and is taken twice a day. It will reduce appetite and can produce weight loss in the 5 to 10% range. Phentermine is taken once in the morning, and is prescribed for a few weeks.

The incidence of liver and bile duct cancer is growing, and about 42,000 new cases are diagnosed each year in the United States. While the incidence is rising, new surgical, interventional, and medical treatments are being added to our therapeutic armamentarium and are available to our patients. After treatment, our team of hepatologists provides continued care to manage the underlying liver disease, preserve liver function, monitor for possible recurrence of cancer, and re-treat, if necessary, while our medical oncologists apply systemic cancer treatment for those in need, as well as access to innovative medications through clinical trials. The Liver Cancer Program at Smilow Cancer Hospital has assembled a dedicated group of specialists, including hepatologists, hepatobiliary and transplant surgeons, diagnostic and interventional radiologists, pathologists, medical oncologists, and nurses. The team meets weekly at a NCI-designated tumor board to discuss each patient’s diagnosis and reaches a consensus on the best personalized treatment plan. Our guiding principle is to personalize and adapt care to the changing needs of the patient. Clinical trials, using new ablation treatment, new targeted agents, and combinations of treatments to target specific intracellular mechanisms of the liver cancer, are also available for patients with advanced disease. A combination of interventional radiology and surgical techniques, including ablation therapy, liver resection, new chemotherapeutic options, and liver transplantation, are available to our patients. For some patients, these treatments can cure their disease. For patients diagnosed with early disease, liver transplantation can provide definitive cure for both the cancer and advanced liver disease that frequently accompanies a diagnosis of cancer. For patients who do not have advanced liver disease or for those who cannot receive a liver transplant, surgical resection and ablative therapies such as transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) can provide excellent survival rates. TACE delivers chemotherapy through a catheter directly to the liver tumor. RFA is a common treatment method for small tumors and uses a direct current to destroy tumors. NanoKnife therapy is a state-of-the-art minimally invasive cancer treatment that applies a high voltage of electrical pulses to induce precision targeted cancer death, while minimizing surrounding tissue damage in the liver. After treatment, our onco-hepatologist team provides continued care to manage the underlying liver disease, preserve liver function, and monitor for possible recurrence of cancer and re-treat, if necessary.

Yale Medicine Gastroenterology (GI) hospitalists are board-certified gastroenterologists who care for patients admitted to the hospital. By focusing solely on hospitalized patients, Yale’s GI hospitalists are a consistent presence in the hospital to provide safe, timely endoscopic procedures, improved interdisciplinary care coordination, and in-depth subspecialty expertise in the management of GI emergencies and complex GI illnesses. They provide efficient, high-quality inpatient care, reducing delays and barriers to endoscopy. The role of hospitalists has expanded since the concept was originally introduced to include subspecialty hospitalists. GI hospitalists improve the quality of care at Yale New Haven Hospital. As emerging leaders in this field, Yale School of Medicine’s GI Hospitalists led the first national conference on inpatient gastroenterology in December 2021. “The GI Hospitalist Model: Addressing the Needs of Hospital-Based Care,” which was organized under three themes: the state of inpatient GI care and the role of GI hospitalists; the benefits of GI hospitalists in clinical and non-clinical fields (education and research); and developing a GI hospitalist program. In March 2022, the team outlined the advantages and challenges of utilizing a hospitalist model in gastroenterology in The American Journal of Gastroenterology. In “Adapting to the Challenge of Hospital-Based Care: The Evolving Role of Gastroenterology Hospitalists,” the authors discuss how having a designated GI hospitalist permits more timely care for acute issues that may arise in the inpatient setting. Adding this role also helps to eliminate disruptions to outpatient and/or endoscopy clinics. Yale School of Medicine’s GI hospitalists are at the forefront of delivering high-quality, effective GI care for hospitalized patients at Yale New Haven Health system.

As hospitalists, our clinic is the hospital ward. Our highly trained physicians take care of children of all ages who are hospitalized for either general illnesses or complex medical situations. Because we are based in the wards, we are readily available to our pediatric inpatients and their families several times a day, and for extended periods at a time. We can quickly respond to our patients' changing needs, coordinate the efficient input of any involved specialty consultants, and provide an important link to community pediatricians. We use a family-centered approach to care, based on good communication and compassion, and are constantly updating our practice to remain on the leading edge of the treatment of childhood diseases.

The Breast Pathology program specializes in interpreting and evaluating core needle breast biopsies, incisional and excisional biopsies, lumpectomy or partial and total mastectomy specimens, sentinel lymph nodes, axillary dissections, prophylactic and oncoplastic reduction mammoplasty, and neoadjuvant breast cases. The faculty is board-certified in anatomic pathology and many of the pathologists also have subspecialty expertise in breast pathology. We provide state-of-the-art diagnostic services focused on precise diagnoses of both benign and malignant breast diseases. In cases with malignant diagnosis, additional ancillary studies for receptors are reported with two- to three-day turnaround times. We work closely with our clinical team to ensure that our patients get accurate and reliable results that are critical to patient care. The first question a breast pathologist seeks to answer when reading a breast biopsy is whether cancer is present. But the information included in the pathology report goes far beyond the “yes” or “no” diagnosis. Even if the biopsy is benign, we need to ensure that the calcifications seen on imaging correlate with calcifications seen on the core biopsy pathology specimen. The earliest stage of breast cancer, called ductal carcinoma in situ (DCIS), is usually detected in this manner. Discordance between pathology and imaging is addressed by means of communication between the radiologist and pathologist in a radiology-pathology conference or by individual communication. A pathology report always has a detailed visual morphologic description of the tumor. The initial biopsy report includes information on whether the cancer is confined within the ducts (in situ carcinoma) or has breached the duct wall and invaded into the adjacent stroma (invasive carcinoma). We provide intraoperative consultation on sentinel lymph nodes in the frozen section suite to detect metastases, which will then help the surgeon in planning patient management. Additional details will be studied and added to the pathological report after mastectomy and sentinel node biopsy to determine whether the cancer has metastasized or spread to any lymph nodes. Tumor size, histologic grade, and lymph node status are prognostic indicators that provide valuable information about the likely clinical outcome. For example, a patient whose tumor is well-differentiated and has negative margins, i.e., has clear margins, has a better prognosis than a patient whose tumor is one that is poorly differentiated and is present at the margin.

Whereas laboratory scientists typically analyze blood or other fluids from patients, anatomic pathologists evaluate tissue specimens, which include cervical scrapings (i.e., PAP smears), biopsies, surgical resections, and whole-body evaluations at autopsy. Anatomic Pathology has three major divisions: Surgical Pathology. This is the examination of tissue removed as a biopsy or as part of a surgical procedure. When a biopsy is done (typically a small sampling of a lesion by incision or by an invasive technique like a core needle biopsy or endoscopy), the pathologist determines what disease process is present, and/or the extent of disease. In all cases, pathologists make their diagnoses by examining thin slices of the lesion under a microscope. Pathologists often also use a variety of specialized molecular techniques to further refine the diagnosis and to predict how the disease may respond to various types of treatment. In this way, the pathologist helps guide any subsequent therapy the patient may need. Cytopathology: This is the examination of very small amounts of tissue removed by scraping a surface, or by aspiration through a fine needle. Obtaining a cytopathology specimen is typically less invasive than obtaining a surgical pathology specimen, so these procedures can be performed in a clinic or a physician’s office. Cytopathologists examine individual cells and small collections of cells to assess for the presence or absence of malignancy. Autopsy Pathology: This is the anatomic examination of a deceased patient to determine what diseases were present and how extensive they were, and to assemble these findings into an explanation for why the patient died. Autopsy examination can answer questions family members may have about the patient’s death, but can also increase understanding of disease for the physicians caring for the patient.