Lower Gastrointestinal Physiology 1

Module details

Title

Lower Gastrointestinal Physiology 1

Type

Specialist

Module code

S-GI-S1

Credits

10

Phase

2

Requirement

Compulsory

Aim of this module

This module will provide trainees with a specialised body of knowledge that underpins Lower Gastrointestinal Physiology. Trainees will gain experience in a range of diagnostic anorectal investigations undertaken to investigate disorders of the lower gastrointestinal tract, interact with patients and demonstrate safe, patient-centered practice. Trainees will be expected to undertake anorectal physiology investigations (anorectal manometry, rectal sensation testing and balloon expulsion testing), build practical skills in setting up and maintaining the equipment used, interpret results and produce reports, take a patient history, explain procedures to patients and gain consent, whilst developing and building their professional practice. Trainees will also build practical skills in setting up and cleaning the equipment for endoanal ultrasound scanning.

Training activities

Assessments

Complete 2 Case-Based Discussions

Complete 2 DOPS or OCEs

Direct Observation of Practical Skills Titles

• Check the calibration of the anorectal catheter before intubation.
• Perform a digital rectal examination prior to an anorectal investigation.
• Apply appropriate infection control precautions when carrying out an anorectal physiology investigation.
• Correctly enter the patient details for the investigation, with reference to their patient record.
• Prepare the room and equipment for an anorectal physiology investigation.

Observed Clinical Event Titles

• Obtain a patient history for anorectal physiology investigations.
• Explain an anorectal physiology procedure to a patient and obtain their informed consent.
• Safely remove and correctly dispose of an anorectal manometry catheter.
• Greet a patient and check their identity.
• Provide a patient with appropriate reassurance and support during an anorectal physiology investigation.

Learning outcomes

Activities

1. Attend pelvic floor multidisciplinary team meetings.
2. Attend a colorectal outpatient clinic, to appreciate reasons for onward referral for anorectal physiology investigations and the patient pathway.
3. Observe a range of lower gastrointestinal imaging investigations e.g., colonoscopy, flexible sigmoidoscopy, proctogram, colonic transit study, barium enema or MRI proctography.
4. Observe pelvic floor physiotherapy sessions to appreciate how pelvic floor physiotherapy can have a role in improving patient symptoms.
5. Observe a rectal irrigation clinic to appreciate how rectal irrigation can have a role in improving patient symptoms.
6. Shadow nurse specialists in a range of services relevant to anorectal physiology investigations e.g., inflammatory bowel disease clinics, pessary clinics, stoma services, bowel and bladder continence services or intestinal failure units.
7. Observe a range of relevant surgical procedures to appreciate how these interventions may impact anorectal physiology investigations e.g., prolapse repair, cancer operations, haemorrhoidectomy, sphincter repair or fistula repair.
8. Shadow a midwife on a labour ward and carrying out post-natal follow ups, to appreciate the impact of childbirth on the pelvic floor.
9. Shadow a dietitian to appreciate the impact of diet on bowel function and stool consistency.

Learning outcomes

On successful completion of this module the trainee will be able to:

1. Differentiate between the range of conditions affecting the lower gastrointestinal system and critically appraise the available surgical and conservative interventions.
2. Critically evaluate the application of anorectal manometry systems.
3. Interpret a range of male and female anorectal physiology investigations including normal and abnormal findings and the identification of artefacts.
4. Critically evaluate the application of sacral nerve neuromodulation and percutaneous tibial nerve stimulation.
5. Differentiate between the pharmacological mechanisms of drugs affecting lower gastrointestinal function in order to select appropriate drugs for presenting conditions.
6. Critically evaluate the relationship between factors impacting upon lower gastrointestinal system function.

Indicative content

• Structure and function of the lower gastrointestinal tract (including the large and small bowel, rectum and anal canal) and anatomy of the pelvic floor
• Structure and function of the pelvic floor, including pelvic floor disorders (types of pelvic organ prolapse, passive and urge faecal incontinence, urinary incontinence and dyssynergic defaecation)
• Neurophysiology and endocrinology of the lower gastrointestinal tract and pelvic floor
• The effect of ageing on the lower gastrointestinal tract and pelvic floor
• The interpretation of male and female anorectal manometry, rectal sensation testing and balloon expulsion testing including the identification of anatomical landmarks and normal ranges of values
• The identification of artefacts during anorectal manometry
• Obstetric anal sphincter injuries, risk factors, how they can be avoided and surgical repair options
• Lower gastrointestinal pharmacology, including biologic agents, laxatives (types, mechanism of action, indications and contraindications), loperamide, and the effects of opioids
• Laboratory tests relevant to the lower gastrointestinal tract (faecal calprotectin, faecal elastase and inflammatory markers)
• Pathophysiology of the lower gastrointestinal tract: Crohn’s disease, ulcerative colitis, diverticulitis, irritable bowel syndrome, passive and urge faecal incontinence, obstructive defaecation, slow transit constipation, haemorrhoids, Hirschsprung’s disease, anal fissure, fistula-in-ano, sepsis, sexually transmitted diseases, congenital and acquired defects, and colorectal and anal cancers
• Overview of surgical interventions for the lower gastrointestinal tract: Delorme’s procedure, Hartmann’s procedure, anterior resection, colonic resection, colostomy, ileostomy, MACE procedures, STARR procedure, THD SphinKeeper, bulking agents, artificial anal sphincter and BOTOX
• Overview of pelvic floor neuromodulation: sacral nerve neuromodulation and percutaneous tibial nerve stimulation, including mechanism of action, indications and contraindications
• Overview of trans-anal irrigation, including indications and contraindications, therapeutic effects and types of equipment available
• Overview of conservative treatments for bowel symptoms: anal plugs, pelvic floor physiotherapy, biofeedback therapy, cognitive behavioural therapy and relaxation training
• Psychology and the lower gastrointestinal tract: psychological stress, anxiety, depression, eating disorders, laxative abuse, obsessive compulsive disorder and the impact of abuse
• Diet and the lower gastrointestinal tract: dietary fibre, low FODMAP diet, probiotics, caffeine and dietary laxatives
• The ranges of anorectal manometry equipment and catheters available (including the advantages and disadvantages of water perfused and solid state) and the principles of how they work
• Clinical history taking skills pertinent to lower gastrointestinal physiologyg