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  • The Whole Person
  • The Medical Patient
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• CARDIORESPIRATORY
  • Cardiovascular System
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• METABOLISM
  • Gastrointestinal System
  • Renal and Urinary System
  • Endocrine System
• HUMAN DEVELOPMENT
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METABOLISM: Gastrointestinal System

Index

• General Outcomes for Gastrointestinal System
• Acute Abdomen
• Diverticular Disease
• Disorders of the Hepato-biliary System
• Nutrition and Malnutrition
• GI Ulcer Disease and Bleeding
• Herniae
• Obstructive Disorders of the GI System
• Trauma to the GI System
• Aneurysms
• Gastrointestinal Cancer
• Diarrhoeal and Inflammatory Disorders
• Vascular Conditions
• GI Surgery and Anaesthetics (General)
• Malabsorption Disorders

• General Outcomes for Gastrointestinal System
  • Medical knowledge: ANATOMY (TD 8.1)
    • Abdominal / Gut Anatomy - General
      1. Outline the basic components that make up the wall of the alimentary tract. (GEP/DGM)
      2. The anatomical basis of the abdominal examination
      3. Know the surgical anatomy of the abdomen including the peritoneum (MET3A)
      4. Define the acronyms MALT and GALT. (GEP/DGM)
      5. Define hernia and list the most common hernias
      6. Describe variations in the basic wall plan at particular sites (i.e. junctions, retroperitoneal regions). (GEP/DGM)
      7. Explain the terms intraperitoneal and retroperitoneal
      8. Describe the changing nature and function of the mucosae in the alimentary tract. (GEP/DGM)
      9. Explain how the mucosa of the small intestine is adapted to increase its surface area for absorption. (GEP/DGM)
      10. Outline the cellular composition of the epithelia in each part of the alimentary tract. (GEP/DGM)
      11. Know the anatomy and blood supply to the stomach and duodenum and their relation to the pancreas (MET3A)
    • Circulation of the Abdomen
      1. Outline the distribution of the coeliac trunk, superior mesenteric and inferior mesenteric arteries
      2. Compare the blood supply of the jejunum and ileum
      3. Describe the main drainage pattern of the portal system
      4. List the main regions of porto-systemic anastomoses and explain their importance
    • Peritoneum
      1. Describe the location and function of the visceral and parietal peritoneum
      2. Outline the embryology of the foregut, the midgut and the hindgut and the formation of the peritoneal cavity
      3. Describe the general arrangements of the gastrointestinal tract and associated viscera
      4. Describe the difference between retroperitoneal organs and intraperitoneal organs
      5. Understand the extent and the sub-divisions of the peritoneal cavity
    • Surface Anatomy of the Abdomen
      1. The anatomical basis of the abdominal examination
      2. List the nine divisions and four quadrants of the abdomen and relate these divisions to the underlying anatomical structures (MET1)
    • The Abdominal Wall
      1. Describe briefly the structure of the abdominal wall
  • Medical knowledge: PHYSIOLOGY (TD 8.2)
    • Gastrointestinal Motility
      1. Describe the control of the lower oesophageal sphincter
      2. Know the normal function of the large bowel (MET3A)
      3. Know the volumes of fluid secreted in the GI tract
      4. Understand the process of fluid losses and replacement in bowel obstruction
      5. Describe the process of gastric emptying
      6. Describe the mechanisms and causes of vomiting
      7. State approximate gastrointestinal transit times
      8. Describe the propulsive and non-propulsive movements of the small and large intestines
      9. Describe the process of defaecation
      10. Define constipation and diarrhoea and list causes of each condition
    • Digestion and Absorption
      1. Compare and contrast the fate of absorbed fat with that of endogenous fat during the post-absorptive phase
      2. Outline the route taken by chylomicra from intestinal mucosa cells to the liver and describe the overall changes in their lipid content during their journey
      3. Describe the synthesis and transport of triacylglycerol from the liver to the periphery as very low density lipo-protein (VLDL)
      4. Describe the roles of the salivary glands, stomach, liver, pancreas and small intestine in the digestion of carbohydrates, lipids and proteins
      5. Distinguish between portal and lymphatic routes of nutrient transport
      6. Describe the main characteristics of the transport systems for amino acids and monosaccharides
      7. Draw a diagram summarising the transformation of very low density lipo-protein (VLDL) to low density lipo-protein (LDL) showing the subsequent fates of the latter
      8. Outline the role of lipoprotein lipase in the hydrolysis of lipoprotein triacylglycerol
      9. Explain how digested lipids are absorbed by the intestinal epithelium. Describe how the lipids are further metabolised and incorporated into chylomicra
      10. Explain how low density lipoprotein (LDL) particles are taken up by cells
    • Gastrointestinal Physiology - General
      1. Critical role of the intestine in animal/human evolution (GEP/DGM, MET1)
      2. Normal gastrointestinal tract (GEP/DGM)
      3. Diseases of oesophagus - Reflux and cancer
      4. Diseases of stomach - acid secretion; cancer and bleeding
      5. Small intestine - absorption; immune system, coeliac disease and inflammatory bowel disease (GEP/DGM)
      6. Summary - reasons for gastroenterology being an interesting and important area in which to work (GEP/DGM)
    • Pancreas
      1. Describe the main structural features of the insulin molecule
      2. Outline how insulin secretion is regulated
      3. Describe the structure of the pancreatic islet of Langerhans; list the major cell types and the hormones that they secrete
  • Medical knowledge: BIOCHEMISTRY (inc. Metabolism) (TD 8.3)
    • Metabolism - General
      1. Define inherited metabolic disorders and list common inherited metabolic disorders. (GEP/DGM)
      2. Discuss the links between metabolism and nutrition
      3. Outline the metabolic impact of Von Gierke's disease. (GEP/DGM)
      4. Explain the significance of linkage between the important metabolic pathways, and their apparent complexity
      5. Outline the biochemical basis and consequences of galactosaemia. (GEP/DGM)
      6. Describe with examples, the coordination of metabolism between the organs and between subcellular compartments
      7. Outline the biochemical basis and consequences of McArdle's disease (GEP/DGM)
      8. Discuss the mechanisms for and the importance of the control of metabolism
      9. Describe the consequences of a deficiency of liver fructokinase or fructose 1-phosphate aldolase. (GEP/DGM)
      10. Outline the inherited metabolic disorders of amino acid metabolism (GEP/DGM)
      11. Describe the consequences of phenylketonuria. (GEP/DGM)
      12. List the genetic causes of dyslipidaemia. (GEP/DGM)
      13. Describe the consequences of familial hypercholesterolaemia. (GEP/DGM)
    • Fat Metabolism
      1. Discuss briefly the significance of lipid as a source of metabolic energy in the human body.
      2. List the major metabolic actions of insulin on glucose and lipid metabolism in the postprandial state
      3. Compare and contrast the biosynthesis and the breakdown of triacylglycerols (triglycerides).
      4. Discuss briefly the hormonal control of triacylglycerol in metabolism.
      5. Describe how fatty acids are delivered from adipose tissue to the mitochondria of cells in other organs.
      6. Describe how fatty acids are degraded by b-oxidation in mitochondria.
      7. Describe in outline how cholesterol is synthesised and metabolised.
    • Energy from Metabolism
      1. Define basal metabolic rate and total energy expenditure and indicate how they can be (a) measured (b) estimated.
      2. Outline the characteristics of muscle slow twitch (type 1) and fast twitch (type 2) fibres.
      3. Compare the metabolic pathways employed during sprinting, middle-distance running and marathons.
      4. Describe how, after digestion, the simple molecules of food are largely broken down to a final common aerobic pathway of energy metabolism in which an acetate group is oxidised in order to power ATP production (Krebs cycle and oxidative phosphorylation)
      5. Distinguish between the two peripheral types of muscle fibre indicating how white fibres favour anaerobic metabolism and red fibres aerobic, endurance related exercise.
      6. Describe the regulatory role of AMP-activated protein kinase (AMPK) in exercise.
      7. Discuss the relative energy expenditure during some common daily forms of exercise.
      8. Describe how AMP affects glucose handling by skeletal muscle.
      9. Explain why the oxidation of pyruvate is a key step in human metabolism.
      10. Understand the mechanism whereby AMPK lowers malonyl-CoA concentrations and allows increased fat oxidation.
      11. Describe the metabolic organisation and role of the Krebs cycle.
      12. Outline the metabolic adaptations occurring during fatigue.
      13. Explain how co-enzymes link oxidative metabolism and ATP synthesis.
    • Glucose and Glycogen Metabolism
      1. Outline the role of liver glycogen as a source of blood glucose during a normal feeding cycle. (GEP/DGM)
      2. Outline the mechanisms of glucose uptake into cells
      3. List the major metabolic actions of insulin on glucose and lipid metabolism in the postprandial state
      4. Define gluconeogenesis and state the tissues in which gluconeogenesis occurs.
      5. Outline the advantages of glycogen as a storage molecule.
      6. Outline the potential metabolic fates of glucose 6-phosphate
      7. State the circumstances under which gluconeogenesis will occur.
      8. Describe the structure of glycogen. (GEP/DGM)
      9. Distinguish between the facilative glucose transporters (GLUT's) with respect to tissue distribution and kinetic characteristics
      10. Describe how fatty acid oxidation facilitates gluconeogenesis.
      11. Understand the significance of the regulatory and kinetic characteristics of glucokinase and hexokinase with respect to their tissue locations and physiological roles.
      12. List the major precursors used for gluconeogenesis, and identify their tissues of origin.
      13. Phosphofructokinase is the major control point of glycolysis. Specify how it responds to cellular messages.
      14. Outline the circumstances under which glycogen synthesis and degradation will occur. (GEP/DGM)
      15. Outline the overall pathway of glycogen synthesis and degradation.
      16. Note enzymes in the gluconeogenic pathway that by-pass irreversible steps in glycolysis (glucose 6-phosphatase, fructose 1,6-bisphosphatase, phosphoenolpyruvate (PEP) carboxykinase, pyruvate carboxylase).
      17. Understand that glycolysis can produce ATP by substrate level phosphorylation.
      18. Understand that the key enzymes glycogen synthase and glycogen phosphorylase are controlled both by reversible phosphorylation.and by metabolite effectors
      19. Outline the hormonal regulation of gluconeogenesis.
      20. Understand the different roles of glycogen storage in muscle and liver. Be aware of the differences in the fate of the glucose 1-phosphate that results from glycogenolysis in muscle and liver.
      21. Lactose (milk sugar) is an important source of galactose. Understand how galactose is metabolized and the cause and consequences of galactosaemia.
      22. Understand the different roles of glycogen storage in muscle and liver.
    • Nitrogen Metabolism
      1. Understand the difference between glucogenic and ketogenic amino acids.
      2. Appreciate the general metabolism of the carbon skeletons and amino groups from amino acids and how this interfaces with carbohydrate and lipid metabolism.
      3. Understand the function of alanine and glutamine in interorgan carbon and nitrogen flow.
      4. Outline how amino groups are funnelled into the urea cycle. Understand why urea is a better excretion product than ammonia.
    • Fatty Acids
      1. Describe the control of fatty acid synthesis via regulation of acetyl-CoA carboxylase.
      2. Understand the purpose of triglyceride mobilisation (lipolysis).
      3. State the products of lipolysis and contrast the metabolic fates of the glycerol and fatty acid moieties in triglyceride.
      4. Understand how the activity of hormone-sensitive (triglyceride) lipase is regulated.
      5. Outline the overall pathway of fatty acid activation and transport into the mitochondrial matrix via the carnitine shuttle.
      6. Be aware of the regulatory importance of malonyl-CoA for regulation of mitochondrial long-chain fatty acid oxidation at the level of carnitine palmitoyl transferase I.
      7. Outline the general features of the beta-oxidation spiral and understand the role of beta-oxidation in ATP production.
      8. State the site and mechanism of ketone body production (ketogenesis).
      9. Specify the fate of ketone bodies in tissues such as the muscle and brain.
      10. Describe the effects of excessive ketone body production.
    • Amino Acids
      1. List three metabolic fates of dietary amino acids.
      2. Define the terms: essential amino acid, non-essential amino acid, carbon skeleton, glucogenic amino acid, ketogenic amino acid.
    • Urea Cycle
      1. Draw the molecular structure of urea, state the average daily output of urea in man, and describe the reactions of the Urea cycle (names only).
    • Nitrogen Balance
      1. Draw a diagram indicating the main components of N intake and excretion in a normal person, and explain the information which can be obtained by N balance studies.
      2. Explain obligatory Nitrogen loss
  • Medical knowledge: PATHOLOGY (TD 8.7)
    • Gastrointestinal System - General Pathology
      1. Outline the changing nature and function of the epithelial lining of the alimentary tract. (GEP/DGM)
      2. Describe the characteristic features of the gastric mucosa.
      3. Draw a diagram of the normal small intestinal mucosa and show what changes occur in enteropathy. (GEP/DGM)
      4. Illustrate the structure of the upper small intestinal wall (serosa to mucosa). (GEP/DGM)
      5. Describe common pathologies of the gastrointestinal tract. (GEP/DGM)
  • Medical knowledge: IMMUNOLOGY and INFLAMMATION (TD 8.8)
    • Immunology - General Outcomes
      1. Appreciate that the gut is a highly vulnerable tissue, susceptible to infections.
      2. Realise that only a single layer of epithelium separates the gut lumen from the tissues.
      3. Appreciate that the gut contains the majority of the immune system in the body
      4. IgA is the secretory immunoglobulin
      5. While the gut epithelium is absorbing nutrients, it is also transporting large amounts of IgA into the gut lumen
      6. Absence of T cells in the gut leads to chronic low grade infections
      7. That mucosal protective immune responses are generated in Peyer's patches and expressed in lamina propria
  • Medical knowledge: NUTRITION (TD 8.11)
    • Obesity
      1. Discuss the important problems in obtaining a reliable nutritional history from obese patients
      2. Enumerate the clinical signs which are relevant to the aetiology or complications of obesity
    • Under nutrition and Malnutrition
      1. Define adult groups who are at particular risk of under nutrition in the UK eg, Vitamin D deficiency in Asians; iron and vitamin deficiencies in Vegans and the elderly (MET3A)
    • General Outcomes for Nutrition
      1. Describe how a patient's energy requirements can be calculated (MET3A)
    • Artificial Feeding (inc. Enteral Nutrition & Total Parenteral Nutrition)
      1. Describe how feeds can be administered: sip feeds; nasogastric and gastrostomy (MET3A)
      2. Explain how artificial feeding techniques minimise the principal complications of aspiration, dehydration, hyperglycaemia, sodium overload and diarrhoea (MET3A)
      3. Describe the techniques of peripheral and central venous parenteral nutrition and how the technique employed may reduce the risk of thrombophlebitis, sepsis, hyperglycaemia and sodium overload (MET3A)
    • Protein Energy Malnutrition (PEM)
      1. Describe the effects of protein-calorie malnutrition on muscle function; delayed hypersensitivity; wound healing and gonadal function (MET3A)
    • Eating Disorders
      1. Outline the management of a patient with anorexia nervosa (MET3A)
  • Medical knowledge: CLINICAL FEATURES of DISEASE (TD 8 b)
    • General Outcomes for Gastrointestinal Disease
      1. How to identify the common clinical signs that signal a patient with abdominal disease is unwell
      2. How to systematically observe a patient from the end of the bed using the 'feet to face' principle, identifying some common abnormalities of abdominal disease
      3. How to perform a systematic examination of a patient with abdominal disease including some peripheral and central clinical signs
      4. Enumerate the clinical signs which are relevant to the aetiology or complications of obesity
  • Clinical skills: HISTORY (TD 13 a-b)
    • Abdominal Examination
      1. The anatomical basis of the abdominal examination
      2. How to gain consent to examine a person/patient's abdomen
      3. Appreciate the examination techniques required to perform superficial and deep palpation of the abdomen (MET1)
      4. How to position a patient/person correctly prior to examining their abdomen
      5. Appreciate the examination techniques required to assess a patient for hepatomegaly and splenomegaly (MET1)
      6. How to identify the common clinical signs that signal a patient with abdominal disease is unwell
      7. Appreciate the examination technique of balloting (for renal enlargement). (MET1)
      8. How to systematically observe a patient from the end of the bed using the 'feet to face' principle, identifying some common abnormalities of abdominal disease
      9. Appreciate how to auscultate for bowel sounds. (MET1)
      10. How to perform a systematic examination of a patient with abdominal disease including some peripheral and central clinical signs
      11. Demonstrate the appropriate techniques required to perform a holistic clinical examination of a patient with abdominal disease
      12. The associated clinical examination and investigations required to complete a clinical assessment of a patient with abdominal disease
      13. Know what a patient with peritonitis board like rigidity is like to examine (MET3A)
    • Patient History for GI Disorders
      1. Understand the significance of complaints of diarrhoea, constipation and altered bowel habit (MET3A)
    • Taking a History
      1. Discuss the important problems in obtaining a reliable nutritional history from obese patients
  • Clinical skills: PLANNING AND INTERPRETING INVESTIGATIONS (TD 14 c-d)
    • General
      1. The associated clinical examination and investigations required to complete a clinical assessment of a patient with abdominal disease
  • Clinical skills: MAKING A DIAGNOSIS and CLINICAL JUDGEMENT (TD 14 e-f)
    • General Outcomes for Gastrointestinal Diagnosis
      1. How to identify the common clinical signs that signal a patient with abdominal disease is unwell
      2. How to systematically observe a patient from the end of the bed using the 'feet to face' principle, identifying some common abnormalities of abdominal disease
      3. How to perform a systematic examination of a patient with abdominal disease including some peripheral and central clinical signs
      4. Know when and how to investigate a patient with diarrhoea, constipation or altered bowel habit (MET3A)
  • Clinical skills: PRESCRIBING DRUGS SAFELY AND EFFECTIVELY (TD 17 a-h)
    • Pharmacological Therapy - Gastrointestinal Disorders (General)
      1. Apply BRAINS&AIMS when choosing, giving and monitoring: 5-Aminosalicylates eg Sulphasalazine; Mesalazine; IV Fluids and Corticosteroids (MET3A)
  • Professional issues: WORKING IN TEAMS (TD 22 a-c)
    • Multi-disciplinary Team Work (MDT)
      1. Describe the role of primary care in the support and monitoring of patients requiring supplementary nutrition (MET3A)
• Acute Abdomen
  • General Outcomes for Acute Abdomen
    1. Recognise the presentation of a patient with an acute abdomen (MET3A)
    2. Be able to take a history of a patient with an acute abdomen (MET3A)
    3. Be able to perform an examination of a patient with an acute abdomen (MET3A)
    4. Be able to elicit guarding (voluntary and involuntary), and rebound tenderness (MET3A)
    5. Able to offer a suitable differential diagnosis (MET3A)
    6. Be able to classify the causes of an acute abdomen (MET3A)
    7. Be able to institute a management plan for a patient with an acute abdomen (MET3A)
    8. Know the indications for referral from primary care (MET3A)
  • Appendicitis
    1. Know the anatomy of the appendix.
    2. Know the different positions of the appendix (retrocaecal, post-ileal, pre-ileal, pelvic) (MET3A)
    3. Describe the surgical anatomy of appendicectomy (MET3A)
    4. Know the classical and alternative presentations of appendicitis (MET3A)
    5. Know the different clinical picture of acute and perforated appendicitis (MET3A)
    6. Know the role of imaging in the diagnosis of appendicitis (MET3A)
    7. Know the differential diagnosis of appendicitis (MET3A)
    8. Be able to discriminate appendicitis from the other differential diagnoses on the patient's history (MET3A)
    9. Describe the blood and urine results in appendicitis (MET3A)
    10. Know the management of an appendix mass (MET3A)
    11. Know the role laparoscopy in the diagnosis and treatment of appendicitis (MET3A)
    12. Know the different surgical approaches to appendicectomy (MET3A)
    13. Know the complications of appendicectomy (MET3A)
    14. Know the aetiology of appendicitis (MET3A)
  • Peritonitis
  • Pancreatitis
    1. Understand the difference between mild and severe pancreatitis (MET3A)
    2. Understand the difference between mild and severe pancreatitis
    3. Be able to describe the early and late complications of acute pancreatitis (MET3A)
    4. Be able to describe the early and late complications of acute pancreatitis
    5. Understand the difference between acute and chronic pancreatitis (MET3A)
    6. Understand the difference between acute and chronic pancreatitis
    7. Know the classical clinical presentation of acute pancreatitis (MET3A)
    8. Know the classical clinical presentation of acute pancreatitis
    9. Know the causes of acute pancreatitis
    10. Know the causes of acute pancreatitis (MET3A)
    11. Know the pathophysiology of acute pancreatitis (MET3A)
    12. Know the pathophysiology of acute pancreatitis
    13. Know the differential diagnosis of acute pancreatitis (MET3A)
    14. Know the differential diagnosis of acute pancreatitis
    15. Know the diagnostic investigations useful for the diagnosis of acute pancreatitis (MET3A)
    16. Know the diagnostic investigations useful for the diagnosis of acute pancreatitis
    17. Know the role of Ultrasound, CT and ERCP in the management of acute pancreatitis (MET3A)
    18. Know the role of Ultrasound, CT and ERCP in the management of acute pancreatitis
    19. Know Atlanta criteria for severity scoring (MET3A)
    20. Know the Atlanta criteria for severity scoring
    21. Know the importance and prognostic value of the scoring systems (Ranson & Glasgow) in patient management (MET3A)
    22. Know the importance and prognostic value of the scoring systems (Ranson & Glasgow) in patient management
    23. Know the current indication for antibiotics in acute pancreatitis (MET3A)
    24. Know the current indication for antibiotics in acute pancreatitis
    25. Be aware that acute severe pancreatitis can lead to multi-organ failure (MET3A)
    26. Be aware that acute severe pancreatitis can lead to multi-organ failure
    27. Describe the principles of management of acute pancreatitis (MET3A)
    28. Describe the principles of management of acute pancreatitis
    29. Be aware of the role of surgery in the management of acute pancreatitis (MET3A)
    30. Be aware of the role of surgery in the management of acute pancreatitis
    31. Be able to describe the epidemiology of pancreatitis (MET3A)
    32. Be able to describe the aetiology of pancreatitis
• Diverticular Disease
  • General Outcomes for Diverticular Disease
    1. Understand the causes of diverticular disease (MET3A)
    2. Understand the complications of diverticular disease (MET3A)
    3. Know the common presentation of a patient with acute diverticulitis (MET3A)
    4. Know the medical management of a patient with acute diverticulitis (MET3A)
    5. Understand the role of surgery in the management of a patient with acute diverticulitis (MET3A)
  • Colonic Diverticulae
• Disorders of the Hepato-biliary System
  • Hepato-biliary Disorders - General
    1. Be able to assess a patient with chronic liver disease
    2. Apply BRAINS&AIMS when choosing, giving and monitoring the following medications: Lactulose; Furosemide; Vasopressin; Phosphate Enema; Vitamin K; Spironolactone; Propranolol; Antibiotics eg Ciprofloxacin; Human Albumin Solution (MET3A)
    3. Give an overview of the role of the liver in carbohydrate, lipid and protein metabolism (GEP/DGM)
    4. Describe the role of the liver in glucose homeostasis (GEP/DGM)
    5. Be able to list the possible causes of acute/chronic liver disease.
    6. Understand the aetiopathology of the more common causes of acute/chronic liver disease
    7. Describe how the liver acts as an organ of detoxification (GEP/DGM)
    8. Discuss the role of the liver in protein synthesis (GEP/DGM)
    9. Be able to understand and interpret the blood tests required to establish a diagnosis
    10. Be able to understand the appropriate radiological investigations required when diagnosis acute/chronic liver disease
    11. Describe the storage functions of the liver (GEP/DGM)
    12. Describe the components of the biliary tree (including the sphincter of Oddi) (GEP/DGM)
    13. Be able to distinguish between the following terms and conditions: cirrhosis; alcoholic liver disease; encephalopathy; hepatitis; oesophageal varices; ascites
    14. Outline the formation and functions of bile (GEP/DGM)
    15. Know the management of ascites in a patient with chronic liver disease
    16. Describe the function of the gallbladder and its control (GEP/DGM)
    17. Give an account of the viral hepatides; describe the epidemiology, clinical features, pathology and complications
    18. Describe the enterhepatic circulation of bile (GEP/DGM)
    19. Describe the origin, metabolism and excretion of bilirubin (GEP/DGM)
    20. Outline the main causes of chronic hepatitis and briefly describe the pathology
    21. Be able to identify patients who are prone to drug-induced liver disease (MET3A)
    22. Be able to identify patients with active drug-induced hepatoxicity (MET3A)
    23. Be aware of the specialist drugs Interferon-a and Ribavirin. Be aware of their important adverse effects and drug-drug interactions (MET3A)
    24. Be aware that there are treatment options in hepatitis C infection (MET3A)
    25. Know how to monitor drug effects in patients with liver disease (MET3A)
    26. Know how to monitor patients for hepatotoxic drug effects (MET3A)
    27. Know which drugs may damage the liver and how this occurs (MET3A)
    28. Know the main indications / contraindications and mechanisms of action of and describe the main adverse effects of vasopressin (MET3A)
    29. Understand how liver disease alters how drugs work; adjust prescriptions in patients with liver disease (MET3A)
  • Acute Hepatitis
    1. Outline the main causes of acute hepatitis and briefly describe the pathology
  • Viral hepatitis
    1. List the drugs currently used for treatment of Hepatitis C
    2. List the approaches to Hepatitis C therapy currently being developed
    3. List the viruses which may cause hepatitis and interpret the results of serological investigations
  • Cirrhosis (General)
    1. Be able to define Cirrhosis and its main causes (MET3A)
    2. Describe the morphological features of cirrhosis and discuss the pathogenetic mechanisms that underlie its complication (MET3A)
    3. Know how to manage a patient with oesophageal varices
    4. Know how to manage an encephalopathic patient
  • Alcohol Related Liver Disease
    1. Describe the effects of alchohol on the liver
  • Hepatic Failure
    1. Describe the systemic effects of hepatic failure
  • Portal Hypertension
    1. Define portal hypertension. List its main causes and complications
  • Cholecystitis
    1. Know the pathology of gallstones (MET3A)
    2. Know the causes of cholecystitis (MET3A)
    3. Be able to differentiate between acute and chronic cholecystitis (MET3A)
    4. Be able to differentiate biliary colic from cholecystitis (MET3A)
    5. Be able to construct a differential diagnosis (MET3A)
    6. Be able to elicit Murphys sign (MET3A)
    7. Know the surgical options for the treatment of gallstones (MET3A)
    8. Know the epidemiology and risk factors for Gallstones (MET3A)
    9. Know the complications of cholecystitis (MET3A)
    10. Know the clinical signs and symptoms of acute cholecystitis (MET3A)
    11. Be able to take an accurate and comprehensive history from an acute patient with cholecystitis (MET3A)
    12. Competently be able to perform an abdominal examination for an acute patient with cholecystitis (MET3A)
    13. Be able to present clinical findings in a clear and logical manner (MET3A)
    14. Be able to describe radiological tests and findings to confirm diagnosis (MET3A)
    15. Be able to institute a management plan for a patient with acute cholecystitis (MET3A)
• Nutrition and Malnutrition
  • General Outcomes for Nutrition and Malnutrition
    1. Outline the role of uncoupling proteins
    2. List the main energy sources present in food
    3. Recall the thermogenic effects of physical activity and food
    4. Define basal (resting) metabolic rate (BMR)
    5. Define energy balance and state how energy requirements are calculated
    6. Discuss the role of vitamins (and trace elements) as antioxidants (MET2)
    7. Give examples of water-soluble vitamins and list the principal function common to B vitamins (MET2)
    8. Describe the clinical syndromes associated with deficiencies of the water-soluble vitamins B1 (thiamin), B6, B12 and folate (MET2)
    9. List the treatment options for obesity
    10. Describe the different methods of nutritional assessment (GEP/DGM)
    11. Describe the prevalence of obesity in the UK and its relationship with the populations' intake of fat and carbohydrate and trends in physical exercise
    12. Give examples of important trace elements present in the diet within the context of clinical features of their deficiencies (MET2)
  • Fasting and Starvation
    1. Understand possible adverse consequences of rapid refeeding after malnutrition
    2. Recall the salient features of anorexia and bulimia
    3. Outline the prevalence and significance of protein-energy malnutrition
    4. Outline the impact of common micronutrient deficiencies on health
    5. Outline the long-term effects of fasting and malnutrition on body composition and metabolism
    6. Define wasting and stunting
    7. Describe how to identify those at risk of malnutrition (GEP/DGM)
  • Anorexia
    1. Recall the salient features of anorexia and bulimia
• GI Ulcer Disease and Bleeding
  • General
    1. Describe the most common cause of peptic ulcer and how this cause is eradicated
    2. Define peptic ulcer and describe the symptoms of ulceration
    3. Define peptic ulceration; list the sites where peptic ulcers can occur (MET3A)
    4. Describe the different types of peptic ulcer and the underlying aetiological factors (MET3A)
    5. Name an important group of ulceragenic (ulcer causing) drugs. Comment on a possible mechanism which may underline this effect
    6. Describe the pathology of peptic ulcers; outline the features that distinguish between peptic ulcers and ulcerating carinomas (MET3A)
    7. Explain the mechanism of action of a named proton pump inhibitor used in the treatment of ulceration
    8. Describe the treatment options for the management of peptic ulceration and non-ulcer dyspepsia (MET3A)
    9. Describe the treatment options for uncomplicated duodenal ulceration (MET3A)
    10. Outline the use of H2 blocking drugs in the treatment of gastric ulceration
    11. Know how to detect and eradicate H.pylori (MET3A, MET3A)
    12. Discuss the management of recurrent peptic ulceration (MET3A)
    13. Discuss the value of endoscopy and barium examinations in the evaluation of patients with peptic ulcer disease (MET3A)
    14. Know how to manage a patient with complicated peptic ulceration (MET3A)
    15. List the complications of peptic ulceration (MET3A)
    16. Know how to manage a patient with dyspepsia in line with current NICE guidelines (MET3A)
    17. List the diagnostic features in a history which are suggestive of peptic ulceration (MET3A)
    18. Outline the causes of peptic ulceration; describe the role of H.pylori and non-steroidal anti-inflammatory drugs in the pathogenesis of peptic ulcers (MET3A)
    19. Be able to recognise the presence of free intra-peritoneal air on plain radiograph and CT Scan (MET3A)
    20. Be able to describe the epidemiology of duodenal and gastric ulceration (MET3A)
    21. Know the common anatomical sites of duodenal ulcer perforation (MET3A)
    22. Know the classical presentation of a patient with a perforated peptic ulcer (MET3A)
    23. Know the initial resuscitative measures in a patient with a perforated peptic ulcer (MET3A)
    24. Know the common causes of peptic ulcer perforation (MET3A)
    25. Understand the variable clinical presentations of a patient with a perforated peptic ulcer (MET3A)
    26. Know the available diagnostic investigations in a patient with perforated peptic ulcer (MET3A)
    27. Know the surgical management of a perforated peptic ulcer (MET3A)
    28. Know the conservative management of a perforated peptic ulcer and its indications (MET3A)
  • Heatburn
  • Gastro-oesophageal Reflux Disease (GORD)
    1. Describe the causes, pathology and complications of gastro-oesophageal reflux disease (GORD) (MET3A)
    2. Apply BRAINS&AIMS when choosing, giving and monitoring: Antacids; H2 receptor blockers eg Ranitidine; Proton Pump Inhibitors eg Omeprazole; Misoprostol; Bismuth Chelate; Metoclopramide; Vasopressin: IV Fluids/Blood (MET3A)
    3. Apply BRAINS&AIMS when choosing, giving and monitoring Antibiotics for H.Pylori eradication eg amoxycillin, clarithromycin, metronidazole; (MET3A)
    4. Understand the term Gastro-oesophageal Reflux Disease (GORD)
    5. Define Barrett's Oesophagus; outline the aetiology, pathogenesis. pathology and complications (MET3A)
    6. Be able to look up the main indications, contraindications, cautions, mechanisms of action, main adverse effects, interactions and dosage regimen of Bismuth Chelate and Vasopressin (MET3A)
    7. Be able to distinguish between the following terms and conditions: Upper / Lower GI Bleeding; Dyspepsia; Gastro-oesophageal Reflux Disease; Peptic / Gastric / Duodenal Ulceration (MET3A)
    8. Be able to discuss non-pharmacological therapy with a patient with GORD or Peptic Ulcer Disease (MET3A)
    9. Describe the therapeutic treatment of gastro-oesophageal reflux disease (GORD)
  • Gastrointestinal Bleeding
    1. Be able to assess whether the patient requires immediate resuscitation (ABC) (MET3A)
    2. Be able to distinguish between upper and lower gastrointestinal bleeding (MET3A)
    3. Be able to list the causes of upper and lower gastrointestinal bleeding (MET3A)
    4. Be able to list the methods of fluid resuscitation (MET3A)
    5. Be able to outline the risk stratification of patients with a high risk of re-bleeding (MET3A)
    6. Know and understand the complications of massive blood transfusion (MET3A)
    7. Know how to manage a patient with an acute GI bleed (MET3A)
    8. Know the aetiopathology of the common causes of lower GI bleeding including: haemorrhoids; diverticular disease; ischaemic colitis; colonic polyps and carcinoma; angiodysplasia; ulcerative colitis (MET3A)
    9. Know the aetiology of common causes of upper GI bleeding including: duodenal ulcer; gastric ulcer; gastric erosions; oesophageal varices; Mallory Weiss tear (MET3A)
    10. Know the anatomy of the coeliac, superior and inferior mesenteric artery territories (MET3A)
    11. Know the endoscopic management of bleeding from the gastrointestinal tract (MET3A)
    12. Know the initial management of gastrointestinal haemorrhage (MET3A)
    13. Know the radiological investigations available for assessment of a gastrointestinal bleed (MET3A)
    14. Know the risk factors for upper gastrointestinal bleeding and the role of the GP in its prevention (MET3A)
    15. Know the role and indication of surgery in the management of gastrointestinal bleeding (MET3A)
    16. Know the role of red cell scanning and interventional radiology in the management of gastrointestinal bleeding (MET3A)
    17. Understand the role of oesophago-gastro-duodenoscopy (OGD) and colonoscopy in the management of gastrointestinal bleeding (MET3A)
• Herniae
  • General Outcomes for Hernia
    1. Know the pathogenesis of femoral hernias
    2. Discuss the formation of inguinal hernias, the relevant anatomy and the possible surgical interventions (GEP/HD, HD2)
    3. Know the causes and associated aetiological factors of femoral hernias
    4. Be able to define the term hernia
    5. Understand the following descriptive terms used to describe hernias: reducible; irreducible; incarcerated; strangulated; sliding
    6. Know and be able to describe the different types of hernia: inguinal; femoral; umbilical; paraumbilical; epigastric; incisional; parastomal
    7. Know the difference between direct, indirect and pantaloon inguinal hernias.
    8. Broadly understand the causes and associated aetiological factors of the other hernias
    9. Be able to take an appropriate history of a patient presenting with a lump in the groin
    10. Be able to perform an appropriate examination eliciting signs that would support the diagnosis of a direct inguinal, an indirect inguinal or femoral hernia
    11. Understand that the diagnosis of a hernia is primarily clinical but certain investigations are available to help delineate the diagnosis
    12. Know the management plan for a patient presenting with direct and indirect herniae; a femoral hernia; a strangulated hernia and a lump in the groin
    13. Know and be able to describe the principles and indications of the various surgical options for the repair of the following hernias: inguinal; femoral; strangulated
    14. Know the princples, indications, contra-indications and complications of the NON-operative management of the following hernias: inguinal; umbilical; epigastric
    15. Know the differential diagnosis for a lump in the groin
    16. Know the embryological development and the associated surgical anatomy of the inguinal and femoral canals
    17. Know and be able to describe the clinical features and presentation of: direct and indirect inguinal hernias; femoral hernias; strangulated hernias
    18. Know which hernias should be repaired surgically
    19. Know the pathogenesis of direct and indirect inguinal hernias
    20. Understand that a strangulated hernia can lead to ischaemia, perforation and sepsis
    21. Understand the principles of and the use of fluids, nasogastric intubation, antibiotics and urinary catheterisation in the stabilisation and monitoring of patients presenting with strangulated hernias
    22. Know that a strangulated hernia is a surgical emergency
• Obstructive Disorders of the GI System
  • Obstructive Jaundice
    1. Understand the physiology of the anatomy of the liver and gallbladder (MET3A)
    2. To be able to describe the physiology of bilirubin metabolism (MET3A)
    3. Understand the differences between conjugated and un-conjugated bilirubinaemia (MET3A)
    4. Be able to list the causes of jaundice (MET3A)
    5. Know the presentation of a patient with obstructive jaundice (MET3A)
    6. To be able to take a focussed history form a patient with obstructive jaundice (MET3A)
    7. Be able to present clinical findings with a patient with obstructive jaundice (MET3A)
    8. Know the relevant blood tests to determine cause of jaundice (MET3A)
    9. Understand the role of ultrasound in a patient with obstructive jaundice (MET3A)
    10. Understand the role of ERCP in a patient with obstructive jaundice (MET3A)
    11. Understand the role of Surgery in a patient with obstructive jaundice (MET3A)
  • Bowel Obstruction (General)
    1. Be able to institute a management plan for a patient with acute bowel obstruction
    2. Competently be able to take an accurate and comprehensive history for an acute patient with bowel obstruction
    3. Competently be able to perform an examination of an acute patient with bowel obstruction
    4. Be able to present clinical findings in a clear and logical manner
    5. Be able to differentiate between a mechanical and dynamic obstruction
    6. Know the difference between simple, complicated obstruction, acute, sub-acute and chronic obstruction
    7. Be able to write up an intravenous fluid regimen for a patient with bowel obstruction
    8. Understand the difference between simple and strangulating intestinal obstruction (MET3A)
    9. Understand the term closed loop obstruction
    10. Know the differential diagnosis for bowel obstruction
    11. Be able to differentiate between small and large bowel on abdominal X-Ray and CT
  • Small Bowel Obstruction
    1. Competently be able to examine a patient with small bowel obstruction (MET3A)
    2. Be able to obtain an accurate history from a patient with an small bowel obstruction (MET3A)
    3. Know the clinical features of small bowel obstruction (MET3A)
    4. Know the cardinal signs of small bowel obstruction (MET3A)
    5. List a differential diagnosis for small bowel obstruction (MET3A)
    6. Know the causes and classification of small bowel obstruction
    7. Know the most common causes of mechanical small bowel obstruction (MET3A)
    8. Understand the biochemical derangements resulting from small bowel obstruction (MET3A)
    9. Know the complications that can result from small bowel obstruction including: ischaemia, perforation and biochemical derangement (MET3A)
    10. Know the appropriate imaging in the investigation of acute abdominal pain including: plain radiography (erect chest X-Ray and abdominal X-Ray), abdominal ultrasound scan, CT scan, contrast studies (MET3A)
    11. Be able to interpret plain abdominal X-Rays showing small bowel obstruction (MET3A)
    12. Know the conservative treatment of small bowel obstruction (MET3A)
    13. Understand the importance of small bowel obstruction as an acute surgical presentation. (MET3A)
    14. Know the indications for surgical intervention and the consequences of resection of small bowel (MET3A)
    15. Know the operative procedures available for small bowel obstruction (MET3A)
    16. Know the possible post-op complications of surgical treatment for small bowel obstruction (MET3A)
  • Large Bowel Obstruction
    1. Know the most common causes and classification of mechanical large bowel obstruction (MET3A)
    2. Understand the biochemical derangements resulting from large bowel obstruction (MET3A)
    3. Know the clinical features and cardinal signs associated with large bowel obstruction (MET3A)
    4. Competently be able to obtain an accurate history from a patient with large bowel obstruction (MET3A)
    5. Know the imaging modalities available to interpret cause of large bowel obstruction (MET3A)
    6. Be able to interpret plain abdominal X-Rays showing large bowel obstruction (MET3A)
    7. Know the complications that can result from large bowel obstruction: (ischaemia, perforation and biochemical derangement) (MET3A)
    8. Understand the importance of large bowel obstruction as an acute surgical presentation (MET3A)
    9. Know the indications for surgical intervention and the consequences of resection of the large bowel (MET3A)
    10. Understand the operative procedures available for large bowel obstruction (MET3A)
    11. Know the possible post-operative complications of surgical treatment (MET3A)
• Trauma to the GI System
  • General Outcomes for GI Trauma
    1. Be able to describe the physiological response to injury
    2. Be able to describe the principles of surgical treatment to the multi-injured patient
    3. Know that the severely injured patient requires a high level of physiological support but also appropriately timed surgical intervention
    4. Understand the concept of damage limitation surgery
    5. Know the importance of an overall team co-ordinator in the management of trauma.
    6. Know the importance of precise and accurate documentation and legal considerations
    7. Know the importance of re-assessment of the patient with regard to earlier interventions
    8. Know the meaning and significance of a patient with polytrauma
    9. Know the meaning of missed injuries and be able to list these
    10. Know the meaning of primary and secondary survey
    11. Know the meaning and importance of triage
    12. Know the scale of trauma in the UK
    13. Recognise the importance of analgesia in the management of trauma patients
    14. Understand the different mechanisms of trauma injury eg blunt v. penetrating / crush v. blast
    15. Understand the importance of a continuum of care for the injured patient by a multi-disciplinary team in which responsibility is actively shared
    16. Understand the importance of the ATLS strategy and systematic approach: rapid primary survey; concurrent resuscitation; secondary survey; continued re-evaluation and monitoring; investigation and definitive care
    17. Understand the role of investigation and treatment is dependent on the haemodynamic status of the patient
  • Abdominal Trauma
    1. Know how to assess priorities during all phases of management of abdominal trauma
    2. Know the importance of classifying abdominal trauma into penetrating and blunt injuries
    3. Know the indication for diagnostic peritoneal lavage in the management of abdominal trauma
    4. Know the indications for operative and non-operative management of a patient with abdominal trauma
    5. Know the management of a patient with bowel, liver or splenic injury
    6. Know the role of computerised tomography (CT) scanning in the management of abdominal trauma
    7. Know the role of laparoscopy in the management of abdominal trauma
    8. Know the role of focussed abdominal ultrasound in the management of abdominal trauma
    9. Know the role of interventional radiology
    10. Understand abdominal compartment syndrome
    11. Understand the role of damage control surgery and its indications
• Aneurysms
  • General Outcomes for GI Aneurysms
  • Abdominal Aortic Aneurysm
• Gastrointestinal Cancer
  • General Outcomes for Gastrointestinal Cancer
    1. Understand the role of the primary care team in the palliative care of terminal gastrointestinal disease. (MET3A)
  • Oesophageal Cancer
    1. Know the aetiology of oesophageal cancer (MET3A)
    2. Know the common presentation of a patient with oesophageal cancer (MET3A)
    3. To understand the medical, surgical and endoscopic treatment of oesophageal cancer including palliation (MET3A)
  • Gastric Cancer
    1. To understand the aetiology of gastric cancer (MET3A)
    2. Know the common presentation of a patient with gastric cancer (MET3A)
    3. To understand the medical, surgical and endoscopic treatment of gastric cancer (MET3A)
  • Liver Cancer
  • Colorectal Cancer
    1. Understand the incidence and prevalence of colorectal cancer (MET3A)
    2. Know the risk factors for colorectal cancer (MET3A)
    3. Know the genetic groups at risk of colorectal cancer (MET3A)
    4. Be able to take a history for a patient with colorectal disease (MET3A)
    5. Be able to perform a examination for a patient with colorectal cancer (MET3A)
    6. Be able to present clinical findings in a clear and logical manner (MET3A)
    7. Know the symptoms and signs of colorectal cancer (MET3A)
    8. To understand the investigations for colorectal cancer (MET3A)
    9. Be able to define the triple assessment for colorectal cancer (MET3A)
    10. Be aware of the importance of multi disciplinary teams in the management of colorectal cancer (MET3A)
    11. Know the surgical treatment of colorectal cancer (MET3A)
    12. Understand the role of the colorectal nurse specialist / colorectal stoma nurse (MET3A)
    13. Be able to recognise a stoma and its problems (MET3A)
    14. Understand the role of palliative care in the management of colorectal cancer (MET3A)
• Diarrhoeal and Inflammatory Disorders
  • General Outcomes for Diarrhoeal and Inflammatory Disorders
    1. Be able to take a history of a patient with diarrhoea (MET3A)
    2. Understand the assessment of a patient with diarrhoea (MET3A)
    3. Be able to request the investigations to establish a diagnosis (MET3A)
    4. Be able to offer a differential diagnosis for a patient presenting with diarrhoea (MET3A)
    5. Be able to understand the different methods of presentation of infectious diarrhoea and inflammatory bowel disease (MET3A)
    6. Compare and contrast the clinical and pathological features of the idiopathic types of Ulcerative Colitis and Crohn's Disease (MET3A)
    7. Know the treatment options for diarrhoea (MET3A)
    8. Understand the public health implications and management of infectious diarrhoea (MET3A)
    9. Describe the clinical features of Crohn's Disease and Ulcerative Colitis; know the main features of other common types of IBD (MET3A)
    10. Abdominal infections and diarrhoea: prophylaxis and treatment of abdominal sepsis; management of infective diarrhoea (rehydration, isolation, notification, antimicrobials), clostridium difficile (CSP3)
    11. Be able to distinguish between the following terms and conditions: increased bowel frequency; diarrhoea; inflammatory / secretory / osmotic diarrhoea; irritable bowel syndrome; diverticular disease; vomiting centre; chemoreceptor trigger zone (MET3A)
    12. Describe the management of acute infective diarrhoea (MET3A)
    13. Describe the pathophysiological mechanisms that may produce diarrhoea (MET3A)
    14. Outline the management of a patient with Crohn's Disease affecting the small bowel (MET3A)
    15. List the causes of diarrhoea and outline the diagnostic features in the history (MET3A)
    16. Be able to distinguish between the following terms and conditions: Crohn's Disease; Ulcerative Colitis; Irritable Bowel Syndrome; Acute Flare; Toxic Megacolon; Infective Diarrhoea (MET3A)
    17. Be able to recognise when surgical referral is appropriate (MET3A)
    18. Know how manifestations of Crohn's depends on site and severity of disease (MET3A)
    19. Know how to manage a patient with active Crohn's Disease in line with current BSG guidelines (MET3A)
    20. Know how to manage a patient with severe ulcerative colitis in line with current BSG guidelines (MET3A)
    21. Understand the role of monitoring patients with inflammatory bowel disease (MET3A)
  • Inflammatory Bowel Disease
    1. Understand from a patient perspective of living with inflammatory disease (MET3A)
    2. Understand the difference between Crohns Disease and Ulcerative Colitis (MET3A)
    3. Be aware of the specialist drugs: Thiopurines eg Azathipprine; Ciclosporin; Methotrexate; Anti-TNFa eg infliximab (MET3A)
    4. Appreciate the mutidisciplinary team approach to the treatment of IBD (MET3A)
    5. Recognise when a patient should be referred for specialist treatment (MET3A)
    6. Use specialist drugs under close specialist supervision only and monitor patients taking these drugs (MET3A)
    7. Understand the medical options of treatment of IBD (MET3A)
    8. Recognise that patients presenting to you unwell, may be so as a result of an adverse reaction these medications; be aware of important adverse effects and interactions to avoid in inadvertent serious drug-drug interactions (MET3A)
    9. Understand the surgical options of treatment of IBD (MET3A)
    10. Understand the following issues with a patient who has an inflammatory bowel disease: importance of nutrition; drugs used to maintain remission; surveillance for colonic cancer; risk of osteoporosis and measures to reduce this; sources of support and info (MET3A)
    11. List the complications of IBD, in particular the extra-intestinal manifestations (MET3A)
    12. Outline the investigation of a patient suspected of having inflammatory bowel disease (MET3A)
    13. Outline the management of a patient with acute ulcerative colitis (MET3A)
    14. Outline the risk of colonic malignancy in IBD; describe the methods used in screening for malignancy in IBD (MET3A)
    15. Be able to take a history from, and examine a patient with inflammatory bowel disease (MET3A)
    16. Be able to implement a strategy for pain control in a patient with inflammatory bowel disease (MET3A)
    17. Be able to recognise potentially life-threatening complications of inflammatory bowel disease (MET3A)
• Vascular Conditions
  • Vascular Conditions - General (See also Cardiovascular System)
  • Ischaemia Disease (See also the CR System)
    1. Describe percutaneous transluminal angioplasty and arterial reconstruction surgery to a patient, including risk of complications
    2. List the indications for amputation and its complications
    3. Explain the process of rehabilitation of the amputee
• GI Surgery and Anaesthetics (General)
  • Surgery - General
    1. Be able to describe the complications from major abdominal surgery (MET3A)
    2. Be able to describe the indications, operations and complications associated with oesophagectomy and gastrectomy (MET3A)
    3. Know the indications, operations and complications associated with laparoscopic cholecystecomy (MET3A)
    4. Know the indications, operations and complications associated with right hemicolectomy, anterior resection and the formation of stoma (MET3A)
    5. Be able to describe the indications, operations and complications associated with Hartman's Operation and abdominoperineal excision of the rectum (MET3A)
    6. Be able to describe the indications, operations and complications associated with splenectomy (MET3A)
    7. Be able to describe the indications, operations and complications associated with treatment for haemorrhoids, fissures and fistula (MET3A)
  • Anaesthetics - General
  • Pre-Operative Assessment
  • Anaesthetics - Post-operative Complications
• Malabsorption Disorders
  • Malabsorption Disorders - General
    1. Outline the management of a patient with short bowel syndrome (MET3A)

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