Informed Consent for Colonoscopy

Please correct the errors described below.

Colonoscopy is a procedure in which your physician can look into your colon with a flexible lighted tube. This tube is about the thickness of your index finger and is inserted into the rectum and advanced slowly into the colon. A small amount of tissue (a biopsy) may be removed and sent to a pathologist for examination under a microscope. Polyps (abnormal growths in the colon), which if left undetected may develop into colon cancer, will be removed and sent to a pathologist for examination.

The benefits of the procedure include the early diagnosis and assistance with treatment of disease of the colon. These diseases might include colon cancer.

There are risks to this procedure, although we believe that the potential benefits outweigh the risks

  1. Bleeding is uncommon (approximately 1 in 400). With severe bleeding, a blood transfusion and/ or surgery may be required.
  2. Perforation (a small hole through the bowel wall) is rare, but if occurs would require hospitalization and surgery.
  3. Colonoscopy is the most accurate diagnostic test available for the detection of polyps and colon cancer, but no test can guarantee 100% accuracy and these lesions can be missed in the course of this exam. There is also a possibility that the exam will be incomplete and that the entire colon will not be able to be examined.
  4. The medication that we give you to prevent pain and discomfort (Versed and Fentanyl), can cause adverse reactions such as severe allergic reactions, redness and swelling of the arm, suppression of breathing, or cardiac arrhythmias. There is also no guarantee that you will be free from pain during the procedure.
  5. Serious heart and lung abnormalities may also occur. Although rare, there is a remote risk of heart attack or stroke.
  6. Injury to internal organs (including spleen, aorta, kidneys liver) is very rare, but if occurs may require surgery to repair.

There are alternatives to colonoscopy, including x-ray studies, but they do not allow the physician to biopsy abnormal areas or remove polyps. In the course of the procedure, pictures may be taken to document findings.

If you want more time to consider this procedure or have further questions, please ask us. Please be aware that delaying the procedure can subject you to a delay in the diagnosis of serious conditions such as colon cancer.

HAVING READ AND UNDERSTOOD THE ABOVE, I FEEL THAT TIIE BENEFITS OF THIS PROCEDURE OUTWEIGH THE RISKS. I HAVE DISCUSSED THE RISKS, ALTERNATIVES, AND HAVE BEEN GIVEN AMPLE OPPORTUNITY TO ASK QUESTIONS.

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