Upper Gastrointestinal Physiology 1

Module details

Title

Upper Gastrointestinal Physiology 1

Type

Specialist

Module code

S-GI-S2

Credits

10

Phase

2

Requirement

Compulsory

Aim of this module

This module will provide a specialist level of knowledge to underpin and be applied to work-based training in Upper Gastrointestinal Physiology. Trainees will have the opportunity to participate in a range of clinical diagnostic investigations of the upper gastrointestinal system while interacting with patients and demonstrating safe, patient-centered practice. They will undertake high-resolution oesophageal manometry and 24-hour ambulatory oesophageal pH monitoring, in addition to developing practical skills in setting up and maintaining the equipment used, interpreting results, producing preliminary reports, explaining procedures to patients and gaining informed consent, while developing and building their professional practice.

Training activities

Assessments

Complete 2 Case-Based Discussions

Complete 2 DOPS or OCEs

Direct Observation of Practical Skills Titles

• Set up and calibrate equipment for high-resolution oesophageal manometry.
• Accurately input patient demographics, indication for referral, catheter details into patient records on a system.
• Safely intubate and extubate a manometry catheter.
• Perform high-resolution oesophageal manometry.
• Set up and calibrate the equipment for a 24-hour ambulatory oesophageal pH/pH-impedance study.
• Input events recorded in a patient diary for analysis of a 24-hour ambulatory oesophageal pH study.

Observed Communication Event Titles

• Obtain a clinical history from the patient in relation to upper gastrointestinal physiology investigations.
• Explain the procedure for oesophageal manometry and 24-hour ambulatory oesophageal pH/pH-impedance monitoring to patients, including the risks and benefits, and obtain the patient’s informed consent.
• Communicate effectively to patients, providing appropriate support and reassurance during manometry to ensure high quality data is recorded.
• Provide information for requirements of pH monitoring, including medications while on test, recording events in diary and unplanned events.

Learning outcomes

Activities

1. Observe upper gastrointestinal endoscopy and barium swallow to appreciate the anatomy and physiology and role in the patient pathway.
2. Observe upper gastrointestinal surgery – for example: anti-reflux surgery,laparoscopic myotomy.
3. Observe endoscopic therapy – for example: Botox, dilatation or POEM.
4. Attend dietetics/enteral feeding clinics.
5. Attend gastroenterology outpatient clinic to understand patient pathway.
6. Attend upper gastrointestinal surgery outpatient clinic to observe patient discussion as part of consideration for surgery.

Learning outcomes

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

1. Differentiate between benign upper gastrointestinal system conditions, and critically appraise the range of investigations available and surgical and conservative interventions.
2. Critically evaluate the range of technologies and techniques used to investigate disorders of the upper gastrointestinal tract.
3. Critically evaluate the physical, psychological and social impact that upper gastrointestinal system conditions have on patients’ well-being.
4. Critically evaluate safe working practice, infection control and quality assurance applied to upper gastrointestinal system investigations.

Indicative content

• Anatomy, physiology of the upper gastrointestinal tract, including:
  • Parasympathetic and sympathetic nerves
  • Intrinsic nerve plexuses, neurotransmitters and hormones
  • Action and control of saliva, gastric acid, pepsin, pancreatic enzyme and bicarbonate, and bile salts and bicarbonate
  • Enzymatic breakdown of protein, polysaccharides and sugars, solubilisation and hydrolysis of fat, mucosal digestion and transport, water and fat-soluble vitamins and vitamin B12 in relation to digestion and absorption.
• Structure and function of the oesophageal sphincters and body, co-ordination of peristaltic contraction
• Neurophysiology – intrinsic neural pathways\plexus, control of swallowing and peristalsis
• High-resolution oesophageal manometry – development and benefits compared to conventional manometry
• Range of oesophageal manometry equipment and catheters – advantages and disadvantages of water perfused and solid-state techniques (including impact different methodologies have on analysis outcome)
• Identification of artefacts during manometry
• Development of threshold of pH4 for pH analysis including parameters that define a reflux episode
• Transducer technology – strain gauges, wheatstone bridge circuits e.g., frequency response, sample rates and resolution
• Upper gastrointestinal pathophysiology/conditions – achalasia, scleroderma, acid reflux, non- acid reflux – relation to extra-oesophageal symptoms, non-cardia chest pain, MS and neuropathies
• Functional symptoms – psychologic impact on oesophageal function
• Medications – groups, side effects, contraindications. Implications of cessation of medication for tests
• Technologies and techniques used to investigate disorders of the upper gastrointestinal tract e.g., intubation/extubation techniques, oesophageal manometry, 24-hour ambulatory reflux monitoring and non-invasive breath testing
•  Normal manometric values for oesophageal function, and application of algorithm to define normal and abnormal
• Normal values for pH analysis – acid exposure time, DeMeester score, symptom association indicies and Lyon consensus
• Surgical/endoscopic interventions – laparoscopic fundoplication, sphincter augmentation (Linx), myotomy,ablation, Botox, dilatation and POEM
• Range of breath tests
• Emerging methodologies and techniques in assessing gut microbiome
• Hierarchy for analysis
• Automatic vs manual analysis
• Patient journey and experience
• Reflection on the scope of practice and when to seek advice