Lower GI Physiology and Endoanal Ultrasound

Module details

Title

Lower GI Physiology and Endoanal Ultrasound

Type

Specialist

Module code

SPS320

Credits

10

Requirement

Compulsory

Aim of this module

This module will provide trainees with a higher specialised body of knowledge that underpins the specialist rotation of Lower GI Physiology. This rotation will enable trainees to perform a range of clinical diagnostic investigations undertaken to investigate disorders of the lower gastrointestinal system, interact with patients and demonstrate safe, patient-centred practice. Trainees will be expected to undertake a range of routine investigations, build practical skills in setting up and maintaining the equipment used, produce reports, interpret results, explain procedures to patients and gain consent, while developing and building their professional practice.

Competencies

#	Learning outcome	Competency	Action
# 1	Learning outcome 1,2,3,4	Competency Control infection risks in accordance with departmental protocols.	Action View
# 2	Learning outcome 1,2,3,4	Competency Minimise risks and hazards in compliance with health and safety policies.	Action View
# 3	Learning outcome 1,3,4	Competency Select suitable technology for each type of investigation, choosing and adapting the appropriate diagnostic technique, patient position, machine settings and transducer for each patient.	Action View
# 4	Learning outcome 1,3,4	Competency Set up equipment ready for use for each type of investigation.	Action View
# 5	Learning outcome 3	Competency Ensure that all anorectal manometry complies with all current safety standards, confirmed by trust BME commissioning number, and that the equipment has been regularly safety-tested and regularly maintained in accordance with the manufacturer’s  recommendations.	Action View
# 6	Learning outcome 1,2,3,4	Competency Obtain a suitably completed request form, greet the patient, check patient identity and ensure that the patient’s identity is confirmed as correct and fully identified on each type of recording system.	Action View
# 7	Learning outcome 1,2,3,4	Competency Explain the procedure for each type of investigation to the patient and address any questions they may have relating to the procedure, including the process after the procedure and how the patient will be informed of the results.	Action View
# 8	Learning outcome 1,2,3,4	Competency Gain informed consent for each type of investigation.	Action View
# 9	Learning outcome 1,2,3,4	Competency Obtain a clinical history as appropriate for each type of investigation, allowing the patient time to describe symptoms and document full relevant history.	Action View
# 10	Learning outcome 1,2,3,4	Competency Treat patients in a way that respects their dignity, rights, privacy and confidentiality.	Action View
# 11	Learning outcome 1,2,3,4	Competency Take appropriate action to respond to the specific needs of as defined by department protocol.	Action View
# 12	Learning outcome 1,2,3,4	Competency Undertake each investigation.	Action View
# 13	Learning outcome 3	Competency Perform further tests, e.g. RAIR, rectal compliance to evaluate the patient’s defaecatory disorder or faecal incontinence as appropriate.	Action View
# 14	Learning outcome 1,3,4	Competency Review the results from each type of investigation, taking into account artefacts, necessary adjustments of values and planned/unplanned events occurring during the test.	Action View
# 15	Learning outcome 1,3,4,5	Competency Compare the values/traces obtained with the normal range/values related to each type of investigation procedure.	Action View
# 16	Learning outcome 1,3,4,5	Competency Produce a clear written report of each type of investigation.	Action View
# 17	Learning outcome 6	Competency Carry out routine maintenance and calibration procedures on the equipment used for each type of investigation.	Action View
# 18	Learning outcome 6	Competency Accurately complete equipment maintenance records and ensure that calibration records and fault reports are accurate, legible and complete for the equipment used for each type of investigation.	Action View

Assessments

You must complete:

• 3 case-based discussion(s)
• 2 of the following DOPS/ OCEs:

Conduct an infection control assessment appropriate to a piece of equipment	DOPS
Accurately input patient demographics.	DOPS
Safely intubate the anorectum and confirm catheter correctly positioned within the anal canal to obtain accurate rectal and anal canal pressures.	DOPS
Obtain baseline measurements and during standard manoeuvres according to local and national standards.	DOPS
Perform sensory awareness tests using balloon distension according to local and national guidance.	DOPS
Safely extubates the patient.	DOPS
Describe the test results to the patient to aid pelvic floor retraining.	DOPS
Set up of the transducer probe including sheath and Selection and use of appropriate transducer characteristics.	DOPS
Safe intubation and extubation of anorectum	DOPS
Obtain clearly labelled images to support the patient report.	DOPS
Appropriate disposal of consumables and cleaning and disinfection of equipment.	DOPS
Accurate use of equipment and software.	DOPS
Explain procedure and the risks and benefits with respect to the patients comorbidities and medication to the investigation to obtain written and informed consent.	OCE
Safely perform a digital rectal examination	OCE
Interpret the data acquired and produce a detailed technical report from a range of patient conditions	OCE
Use safe working methods to reduce cross infection.	OCE
Accurate Input of patient demographics.	OCE
Produce accurate patient report	OCE
Manage a patient during the endoanal ultrasound	OCE
Take accurate and appropriate clinical history and take informed consent for a procedure	OCE

Learning outcomes

1. Continue to perform and produce reports on non-invasive breath tests (hydrogen, methane – if there is a methane analyser available – and urea breath testing).
2. Perform rectal digital examination to ensure safe rectal intubation with manometric and ultrasound equipment.
3. Perform anorectal manometry procedures in patients presenting with a range of conditions, for example obstetric trauma, pre- and post-surgical defaecatory problems, slow transit constipation, obstructive defaecation, neurological disorders.
4. Perform endoanal ultrasound investigations in patients presenting with a range of conditions, including obstetric and surgical trauma, sepsis, fissures, faecal incontinence and obstructive defaecation.
5. Interpret the data and produce clinical reports with respect to non-invasive breath testing, anorectal manometry, balloon distension, compliance, capacity and sensory awareness; endoanal ultrasound being able to differentiate between artefact and physiological occurrence.
6. Carry out routine maintenance and calibration procedures on equipment used in anorectal manometry and endoanal ultrasound.

Learning outcomes

1. Describe lower gastrointestinal (GI) anatomy, physiology and neurophysiology, and apply knowledge to the pathophysiology, investigation and treatment of lower GI disorders.
2. Describe the pathophysiology of lower GI disorders.
3. Explain the principles of sacral nerve and posterior tibial nerve neuromodulation in the treatment of faecal and urinary incontinence.
4. Explain the principles of ultrasound and its use in lower GI investigations and critically evaluate the accuracy, precision and sources of errors.
5. Discuss and critically evaluate a range of technologies, instrumentation and techniques used to investigate the lower GI tract, including endoanal ultrasound and anorectal manometry.
6. Explain the indications, modes and choice of technology to investigate lower GI disease, including small bowel motility disorders.
7. Discuss the techniques used to assess GI motility.
8. Explain the principles and procedure for performing a digital rectal examination and the role of the technique in the assessment of GI disorders.
9. Describe intubation and extubation techniques and apply knowledge to discuss and justify the clinical concepts of safe intubation of the lower GI tract, including infection control and asepsis.
10. Discuss and justify the investigation of benign lower GI disease in a broad patient range, e.g. paediatric, adult, elderly.

Indicative content

Anatomy and physiology

• Structure and function of the lower GI tract, including large and small bowel, anal sphincter complex

Neurophysiology

• Parasympathetic and sympathetic nerves
• Intrinsic nerve plexuses
• Neuromodulation and concept of neurotransmitters
• Hormones in relation to lower GI tract

Pathophysiology of lower GI disorders

• Inflammatory bowel disease
• Irritable bowel syndrome
• Eosinophilic oesophagitis
• Small bowel pathology
• Obstructive defaecation
• Faecal incontinence
• Slow transit constipation
• Haemorrhoids
• Congenital and acquired anatomical defects
• Sepsis
• Obstetric trauma 

Pharmacology

• The effect of lidocaine
• Bulking, osmotic and stimulant laxatives
• Loperamide
• Opiods, opioid-receptor agonist
• Diltiazem
• Nitrates
• Botox
• Colonic irrigation

Device design and technology

• Types of manometric systems
• Modes and principles of ultrasound and its application in lower GI investigation
• Sacral nerve and posterior tibial nerve stimulation

Activities

• Observe the performance of colonic transit studies in patients presenting with a range of conditions, including slow-transit constipation and obstructive defaecation (pelvic floor dyssynergia), and discuss the clinical utility of the investigation and the interpretation of the results.
• Observe endoscopy, barium enema, barium pneumocolon, magnetic resonance imaging (MRI) proctography in a range of patients with conditions related to the lower gastrointestinal system, gain experience in the interpretation of the images produced at endoscopy and report to the educational supervisor on the experiences gained.
• Observe intubation of the lower gastrointestinal tract, including infection control and asepsis, and discuss with your educational supervisor.
• Observe extubation techniques of the lower gastrointestinal tract and methods of infection control and asepsis and discuss with your educational supervisor.
• Identify a patient with lower gastrointestinal symptoms and, with permission, follow the progress of the patient from the initial consultation through investigations, follow-up appointment and/or surgery, and reflect on your learning from this process.

 It is also recommended that trainees undertake the following clinical experiential learning:

•  Observe three-dimensional endorectal ultrasound, positron emission tomography (PET), computed tomography (CT), histopathology, operating theatre and multidisciplinary team (MDT) meetings and discuss how the applications of technology fit in the investigation and therapy of disorders of the lower gastrointestinal system.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of patients with disorders of the lower gastrointestinal system.
• Observe procedures such as antegrade colonic enema (ACE) and Malone antegrade colonic enema (MACE) procedures, stoma surgery and aftercare with stoma nurses, percutaneous tibial nerve stimulation (PTNS) therapy, temporary and permanent sacral nerve stimulation (SNS) implantation, curative resection for colonic and rectal tumours.