Upper Gastrointestinal Physiology 2 —
Training activity: 3

Details

Perform, analyse and interpret oesophageal manometry studies on a range of patients with the following complex presentations:

• Cricopharyngeal abnormality
• OGJ outflow disorders
• Peristalsis disorders
• Surgically altered oesophagus
• Large hiatus hernia
• Rumination syndrome

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

• What does success look like?
  • Identify what is expected of you in relation to achieving competence in high-resolution oesophageal manometry, particularly for complex cases (e.g., OGJ outflow disorders, rumination syndrome).
  • Consider how the learning outcomes apply, specifically in relation to interpreting manometric patterns in the proximal oesophagus / cricopharynx, differentiating between artefact and physiological occurrences, and considering pharmacological influences.
  • Discuss with your training officer to gain clarity of what is expected of you in relation to specific manometric patterns associated with conditions like surgically altered oesophagus or OGJ outflow disorders, and effective communication of procedures/findings.
• What is your prior experience of this activity?
  • Think about what you already know about oesophageal anatomy, physiology, common motility disorders, and the procedure for performing manometry.
  • Consider possible challenges you might face during the activity, such as interpreting manometric patterns for complex cases (e.g., surgically altered oesophagus), managing pharmacological interactions, or patient positioning difficulties.
  • Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if anatomical challenges (e.g., surgically altered oesophagus) cause intubation difficulties, or if manometric patterns suggest rare motility disorders.
  • Acknowledge how you feel about the responsibility of performing and interpreting manometry on complex patients.
• What do you anticipate you will learn from the experience?
  • Consider the specific skills you want to develop, such as technical skills in performing manometry on complex or challenging patients and efficiently interpreting manometric data from patients with complex presentations.
  • Identify the specific insights you hope to gain into interpreting manometric patterns in the proximal oesophagus / cricopharynx and managing potential complications during the procedure.
• What additional considerations do you need to make?
  • Consult actions identified following previous experiences of reviewing manometry protocols and guidelines related to complex cases.
  • Identify important information you need to consider before embarking on the activity, such as reviewing anatomical considerations and potential intubation challenges relevant to conditions like surgically altered oesophagus.

In action

• Is anything unexpected occurring?
  • Are you noticing anything surprising or different from what you anticipate whilst performing the study or analysing the manometric data for a complex patient?
  • Are you encountering situations such as:
    • Difficulty arises in intubating the patient due to anatomical changes (e.g., surgically altered oesophagus), challenging the standard technique?
    • The patient experiences severe symptoms (e.g., pain, spasm) during the procedure, compromising data acquisition and patient safety?
    • Analysis reveals a highly complex pattern (e.g., borderline OGJ outflow disorder or ambiguous proximal motility, that does not neatly fit Chicago Classification criteria?
• How are you reacting to the unexpected development?
  • How is this impacting your actions? For example, are you responding to the situation appropriately?
  • Are you adapting or changing your approach to intubation technique, patient management, or analysis methodology?
  • Consider the steps you are taking in the moment, such as:
    • Immediately pausing the procedure to adjust the patient’s position or reassure them, ensuring compassionate practice.
    • Halting the analysis to review specific guidelines for interpreting manometric patterns in surgically altered oesophagus.
  • How are you feeling in that moment? For instance, are you finding it difficult to maintain technical precision while managing a complex cricopharyngeal abnormality? Is it affecting your confidence in accurately applying diagnostic criteria to the ambiguous pattern?
• What is the conclusion or outcome?
  • Identify how you are working within your scope of practice. For example, are you successfully resolving technical artefacts and obtaining sufficient valid swallows? Or are you needing support because the patient’s severe symptoms or anatomical complexity requires senior clinical intervention or termination of the study?
  • What are you learning as a result of the unexpected development? For example, are you mastering techniques for interpreting manometric patterns in the proximal oesophagus / cricopharynx? Or gaining insight into the difficulties of applying diagnostic criteria to complex OGJ outflow disorders?

On action

• What happened?
  • Begin by summarising the key steps you took when performing the manometry studies and analysing the resulting traces for complex presentations (e.g., OGJ outflow disorders, surgically altered oesophagus, Rumination syndrome).
  • Consider specific events, actions, or interactions which felt important, such as how you managed probe insertion for a cricopharyngeal abnormality or how you applied interpretation guidelines (like the Chicago Classification) to ambiguous patterns.
  • Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adjusting your intubation technique due to unexpected anatomical resistance or halting analysis to differentiate an artefact from a physiological occurrence.
  • How did you feel during this experience, e.g., did you feel focused on technical precision or stressed by the complexity of the interpretation required for peristalsis disorders?
• How has this experience contributed to your developing practice?
  • Identify what learning you can take from this experience regarding performing complex manometry and analysis.
  • What strengths did you demonstrate, e.g., ability to differentiate between artefact and physiological occurrences?
  • What skills and/or knowledge gaps were evident, e.g., uncertainty in interpreting manometric patterns in the proximal oesophagus / cricopharynx or difficulty integrating pharmacological factors?
  • Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved?
  • Has your practice improved in efficiently analysing and interpreting manometric data for complex cases?
  • Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding applying diagnostic criteria to borderline OGJ outflow disorders or interpreting surgically altered oesophagus patterns, and how you reacted to this.
• What will you take from the experience moving forward?
  • Identify the actions you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to performing and interpreting manometry for complex patients.
  • What will you do differently next time you approach complex manometry studies, for instance, by proactively reviewing academic content on patterns associated with rumination syndrome or surgically altered oesophagus?
  • Do you need to practise any aspect of the activity further, such as interpreting manometric patterns in the proximal oesophagus or key learning outcomes related to differentiating between artefact and physiological occurrences?

Beyond action

• Have you revisited the experiences?
  • How have your subsequent experiences of performing adjunctive tests or producing reports since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, interpreting a borderline OGJ outflow disorder forced you to re-evaluate the precision of your initial manometric measurements and the application of the Chicago Classification criteria during your first attempt at this training activity.
  • Considering what you understand about complex anatomical considerations, interpretation of cricopharyngeal patterns, and applying criteria now, were the actions or considerations you identified after your initial reflection on this training activity sufficient?
  • How have you since implemented or adapted improvements in your technical and analytical approach based on further learning and experiences? For example, how you proactively reviewed and integrated specific guidelines for interpreting motility patterns in surgically altered oesophagus, demonstrating you have adapted improvements based on further learning.
  • Has discussing complex manometric findings (e.g., OGJ outflow disorders) or the difficulty in interpreting proximal oesophagus patterns with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a case of rumination syndrome refined your understanding of the critical nature of systematic analysis and differentiation of physiological movements.
• How have these experiences impacted upon current practice?
  • How has the learning from this initial training activity, in combination with subsequent procedural experiences and reporting, contributed to your overall confidence and competence in performing and interpreting manometry studies for complex patients, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in applying the Chicago Classification to complex motility disorders now enables you to confidently discuss a complex oesophageal manometry investigation with a colleague during an Observed Communication Event (OCE) assessment.
  • How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to manometry procedure and analysis?
  • How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the Training Officer or specialist clinician immediately when manometric patterns suggest a rare cricopharyngeal abnormality or if pharmacological interactions severely compromise interpretation, recognising this falls outside routine scope.

Relevant learning outcomes

#	Outcome
# 1	Outcome Perform high-resolution oesophageal manometry in the complex patient, including a full range of adjunctive tests as appropriate.
# 4	Outcome Analyse and interpret the data producing preliminary reports from high-resolution manometry (HRM), differentiating between artefact and physiological occurrences.
# 6	Outcome Employ effective communication skills to present information to a variety of audiences including patients, carers and healthcare professional colleagues.
# 7	Outcome Interpret manometric patterns in the proximal oesophagus/crycopharynx and identify abnormalities, using knowledge from the wider multidisciplinary team.
# 8	Outcome Identify situations where physiological measurements are affected by pharmacological interactions and the impact this may have on test results.