Upper GI Physiology

Module details

Title

Upper GI Physiology

Type

Specialist

Module code

SPS322

Credits

30

Requirement

Compulsory

Aim of this module

This module will provide the trainee with a specialised body of knowledge that will underpin and be applied in the specialist work based training in Upper Gastrointestinal Physiology. This rotation will enable trainees to perform a range of clinical diagnostic investigations undertaken to investigate disorders of the upper gastrointestinal system, interact with patients and demonstrate safe, patient-centred practice. Trainees will be expected to undertake a range of 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	Competency Control infection risks in accordance with departmental protocols.	Action View
# 2	Learning outcome 1,2,3	Competency Minimise risks and hazards in compliance with health and safety policies.	Action View
# 3	Learning outcome 1,2,3	Competency Select suitable technology for each type of investigation, choosing and adapting the appropriate diagnostic technique, patient position, machine settings and transducer	Action View
# 4	Learning outcome 1,2,3	Competency Set up the equipment ready for use for each type of investigation and critique the equipment and consumables available in the investigation of upper gastrointestinal  motility disorders.	Action View
# 5	Learning outcome 1,2,3	Competency Obtain a suitably completed 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
# 6	Learning outcome 1,2,3	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
# 7	Learning outcome 1,2,3	Competency Gain informed consent for each type of investigation.	Action View
# 8	Learning outcome 1,2,3	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
# 9	Learning outcome 1,2,3	Competency Treat patients in a way that respects their dignity, rights, privacy and confidentiality.	Action View
# 10	Learning outcome 1,2,3	Competency Take appropriate action to respond to the specific needs of the patient, as defined by department protocol.	Action View
# 11	Learning outcome 1,2,3	Competency Undertake each investigation/procedure.	Action View
# 12	Learning outcome 2,3	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
# 13	Learning outcome 2,3	Competency Compare the values/traces obtained with the normal range/values related to each type of investigation procedure.	Action View
# 14	Learning outcome 4	Competency Produce a clear written report of each type of investigation.	Action View
# 15	Learning outcome 5	Competency Carry out routine maintenance and calibration procedures on the equipment used for each type of investigation.	Action View
# 16	Learning outcome 5	Competency Accurately complete equipment maintenance records and ensure that calibration records and fault complete for the equipment used for each type of investigation/procedure.	Action View

Assessments

You must complete:

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

Calibrate and check flow rates and transducer function according to Standard operating procedures HRM, solid state and or water perfused as appropriate.	DOPS
Standard operating procedures HRM, solid state and or water perfused as appropriate.	DOPS
Obtain measurements using either standard pull through technique applicable to HRM, standard solid state and water perfused manometric systems according to local and national standards.	DOPS
Perform a minimum of ten test swallows and perform additional swallow assessments as per local protocol.	DOPS
Safely extubate the patient and uses safe working methods to reduce cross infection.	DOPS
Conduct an infection control assessment appropriate to a piece of equipment	DOPS
Check patient details and accurately input patient demographics	OCE
Take detailed history, including medication and confirm appropriateness of investigation.	OCE
Safely intubate the oesophagus with the manometry catheter and confirm catheter correctly positioned within the stomach and oesophagus	OCE
Assess the upper oesophageal sphincter function in terms or relaxation and coordination.	OCE
Correlate technical data with the clinical data to produce a clinical report	OCE
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

Learning outcomes

1. Perform safe intubation of the upper gastrointestinal tract in a range of patients presenting with dysphagia, chest pain, typical and atypical gastro-oesophageal reflux symptoms, exacerbation of chest conditions (asthma, cystic fibrosis), and conditions including achalasia, Barrett’s oesophagus, scleroderma, non-cardiac chest pain, rumination, laryngopharyngeal reflux, Schatzki’s ring, oesophageal webs.
2. Perform oesphogeal manometry (gaining experience of a range of water- based and solid state systems, including high-resolution manometry) in a range of patients presenting with conditions including achalasia, Barrett’s oesophagus, scleroderma, non-cardiac chest pain, Schatzki’s ring, oesophageal webs.
3. Perform single and dual channel pH and combined pH and impedance monitoring in a range of adult patients presenting with a range of conditions, including gastro-oesophageal reflux, duodenogastric reflux, rumination and laryngopharyngeal reflux.
4. Interpret the data and produce high-quality reports with respect to oesphogeal manometry and pH and impedance monitoring, being able to differentiate between artefact and physiological occurrence.
5. Carry out routine maintenance and calibration procedures on equipment used in oesphogeal manometry and pH and impedance monitoring.

Learning outcomes

1. Describe upper gastrointestinal (GI) anatomy, physiology and neurophysiology and apply knowledge to the pathophysiology, investigation and treatment of upper GI disorders.
2. Explain the indications, contraindications, side effects and mode of action of drugs used to treat upper GI disorders and other common drugs that may affect the upper GI system.
3. Discuss and critically evaluate a range of equipment including catheter design and technology used to investigate upper GI investigation.
4. Describe and critically assess a range of techniques used in the investigation of the upper GI tract.
5. Explain the principles with regard to safe working practice, infection control and quality assurance when undertaking upper GI investigations.
6. Explain the indications, modes and choice of technology to investigate upper GI disease.
7. Discuss and evaluate the techniques used to assess upper GI motility.
8. Discuss and critically evaluate a range of extubation techniques and the potential advantages, disadvantages and complications.
9. Discuss and justify the rationale and procedures for the investigation of benign upper GI disease in a broad patient range, e.g. paediatric, adult, elderly.

Indicative content

Anatomy and physiology

• Structure and function of the upper GI tract including the action of sphincters
• Peristalsis
• Voluntary and involuntary movement
• Striated muscle within the GI tract

Neurophysiology

• Parasympathetic and sympathetic nerves
• Intrinsic nerve plexuses
• Concept of neurotransmitters and hormones in relation to GI tract

Pathology

• Malabsorption
• Achalasia
• Carcinoma
• Acid and non-acidic reflux and its role in the exacerbation of extra- oesophageal symptoms
• Extra-oesophageal reflux
• Peptic ulcer disease
• Gluten-sensitive enteropathy
• Dysphagia
• Autonomic neuropathy
• Collagen disorders

Pharmacology

• The effect of H2 receptor antagonists
• Prokinetics
• Proton pump inhibitors
• pylori eradication regimen
• Lidocaine
• Bismuth
• Sucralfate
• Nitrates
• Calcium antagonists
• Botox
• Management of cessation of medication

Device design and technology

• Types of manometric systems
• MII and pH sensors
• Electrode characteristics and function
• Programmable functions and monitoring devices including telemetry

Intubation technique and complications

• Environmental requirements and considerations
• Equipment required
• Intubation procedures and techniques
• Measurements and checks taken at implantation and their significance
• Normal acceptable values for measurements
• Documentation requirements
• Implications of cessation of medication
• Early and late complications and their significance

Follow-up

• Equipment and personnel
• Clinic design
• Databases and patient records
• Patient support material
• Emergency equipment
• Troubleshooting
• Optimal monitoring procedures 

Paediatric considerations

• Indications, intubation and complications

Associated regulations

• Conduct of clinical trials
• Ethical aspects of device implantation

Activities

• Attend clinics at which patients with gastrointestinal disease present, discuss the presenting complaints, initial and follow-up visits, and reflect on the impact of gastrointestinal disease on the patient and their quality of life.
• Attend an operating theatre to observe the treatment of gastro-oesophageal reflux disease i.e. Nissen Fundoplication
• Attend endoscopy and observe the process of endoscopy, botox therapy, balloon dilatation and therapeutic ablation techniques in patients with Barrett’s oesophagus, insertion of stent and sclerotherapy for varices, and discuss the experience with your supervisor.
• Take part in a multidisciplinary meeting and reflect on the way the multidisciplinary team contributes to the care of patients with  gastrointestinal conditions.
• Identify a patient with upper gastrointestinal symptoms and, with permission, follow the progress of the patient from the initial consultation through investigations, follow-up appointments and, if applicable, surgery, and reflect on your learning from this process.

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

• Observe a patient undergoing cardiac work-up, including cardiac angiography and exercise stress testing, to illustrate how the differential diagnosis of the patient presenting with chest pain is made to determine if the pain is arising from the heart or gastrointestinal system.
• Observe oesophageal ultrasound in the investigation of upper gastrointestinal tumours.
• Attend an ENT clinic to observe laryngoscopy to illustrate how the differential diagnosis of the patient presenting with voice disorder and persistent cough is made to determine if the symptoms are arising from the upper gastrointestinal tract.
• Attend a paediatric unit to see how children with disorders of the upper gastrointestinal tract are investigated and treated.