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Elective Rotation

Rotation Description

The Dartmouth-Hitchcock Gastrointestinal Motility Center (DHGMC) is a specialized center of excellence located within the Section of Gastroenterology and Hepatology of Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. The center is staffed by physicians, advanced practice providers, nurses, allied health care workers, and research assistants who have specialized training in the evaluation, diagnosis, and treatment of patients with gastrointestinal motility disorders.
The DHGMC motility rotation is designed to develop the Gastroenterology fellow’s ability to understand and assess motility related GI problems. This includes GI disorders that are primary motility disorders as well as functional disorders. Functional disorders are common disorders that all Gastroenterologists can expect to see on a regular basis throughout their career. A solid understanding of these disorders will allow trainees to optimize their ability to diagnose and manage these patients. 

The DHGMC is an ideal location to learn about motility disorders, as there is a concentration of physicians and multidisciplinary team members with specific interest, specialized training, and extensive experience in motility disorders. 

Although the center has extensive experience in diagnosing and treating all varieties of motility disorders, some of the most common motility disorders referred for evaluation include the following: 

  • achalasia
  • dysphagia 
  • gastroesophageal reflux disease (GERD) and Non-Acid Reflux (NAR)
  • dyspepsia
  • gastroparesis
  • constipation
  • diarrhea
  • irritable bowel syndrome
  • chronic intestinal pseudo-obstruction
  • fecal incontinence
  • pelvic floor dysfunction (pelvic floor dyssynergia)

The DHGMC has state-of-the-art technology for evaluation and management of motility disorders including the following:

  • 24 hour combined pH/multichannel intraluminal impedance testing
  • High-resolution esophageal manometry
  • BRAVOTM wireless pH probes
  • EndoFLIPTM impedance planimetry
  • Gastric emptying scintigraphy 
  • SmartpillTM motility testing system
  • Hydrogen breath tests 
  • High-resolution and 3D anorectal manometry
  • Balloon expulsion testing
  • Magnetic resonance (MRI) defecography

Nearly 1,000 motility tests are performed and interpreted per year. During this rotation the fellow will observe motility testing being performed and learn to interpret the results. Indications and contraindications of various tests as well as the benefits of one modality over another will be emphasized. By the end of this rotation, the trainee can expect to be comfortable with the various motility tests.

There may be opportunities to learn about therapeutic endoscopy techniques during the rotation including balloon dilation for benign esophageal strictures, pneumatic balloon dilation for achalasia and ablation therapies for Barrett’s esophagus. Exposure to peroral endoscopic myotomy (POEM) treatment for achalasia may also be encountered during the rotation. 

The fellow will attend specialized motility disorder clinics and educational rounds with the staff physicians (see schedule and teaching sessions outline). There will be specific sessions with radiologists to learn about barium studies, MR defecography and gastric emptying scans. Additionally the trainee will have dedicated time with the motility dietitian and psychologist to learn about non-pharmacologic treatments for motility disorders. This multidisciplinary approach is part of the evolution to create new models for health care delivery to address the unique needs of patients with motility disorders. 

Rotation Curriculum

In addition to scheduled clinics and endoscopy, the motility rotation curriculum includes observation of motility testing as well as interpretation of test results. Practice cases will be reviewed early in the rotation to help familiarize the trainee with examples of common abnormalities. Trainees will independently analyze each week’s motility tests then have the opportunity to review their interpretations with the attending staff as per a dedicated schedule. 

A typical week involves the following observation and interpretation components:

  1. 24-hour combined esophageal pH/impedance testing
  2. High resolution esophageal manometry testing
  3. BRAVO wireless probe esophageal pH testing 
  4. High resolution anorectal manometry and balloon expulsion testing
  5. EndoFLIP probe esophageal testing (subject to availability)

There will also be regular interactive teaching sessions discussing motility testing and disorders over the rotation period. Trainees will also be invited to attend a weekly lunchtime motility rounds during which unusual or difficult cases are discussed amongst the multidisciplinary team. The fellow will be expected to present two teaching sessions of their choice as well as two journal clubs to further develop their own teaching and critical appraisal skills. The trainees will also have an opportunity to discuss potential involvement in research projects. The DHGMC group has extensive research experience and contacts to help facilitate research. Visiting fellows are welcome to attend the DH GI fellowship training sessions during the rotation. 

Funding

Dartmouth-Hitchcock does NOT provide any funding for visiting fellows. Trainees are expected to self-fund their rotations. Please note that the American Neurogastroenterology and Motility Society (ANMS) does provide $2,000 stipend for selected gastroenterology fellows. Please see the Motility Society website for further details.

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