Informed Consent for Gastrointestinal Endoscopy

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Explanation of Procedure

Direct visualization of the digestive tract with lighted instruments is referred to as gastrointestinal endoscopy. Your health care provider(s) advised you to have this type of examination. The following information is presented to help you understand the reasons for and the possible risks of these procedures. During the examination, the lining of the appropriate portion of the digestive tract will be inspected thoroughly and possibly photographed/filmed. If an abnormality is seen or suspected, a small portion of tissue (biopsy) may be removed for microscopic analysis. Growths (such as polyps), if seen, may be removed.

To keep you comfortable during the procedure, your physician or a nurse directed by the physician will administer medication defined as moderate (conscious) sedation. If deemed necessary by your provider, an anesthesiologist will be present to administer sedation.

Brief Description of Endoscopic Procedures

EGD (Esophagogastroduodenoscopy): Examination of the esophagus, stomach, and duodenum. If active bleeding is found, treatment may be given to stop bleeding.

Esophageal Dilation: Dilating tubes or balloons are used to stretch the esophagus.

Esophageal Varices or Hemorrhoid Banding: A rubber band is placed around the varices/hemorrhoid to reduce the flow of blood to the vein, thus preventing further bleeding. Injection of a chemical into the esophageal varices with a small needle through the scope may be warranted to sclerose (harden) the vein to prevent further bleeding.

Flexible Sigmoidoscopy: Examination of the anus, rectum and left side of the colon, often to a depth of 60 cm.

Colonoscopy: Examination of all or a portion of the colon. Older patients and those with extensive diverticulosis are more prone to complications. Polypectomy (removal of growths called polyps) is performed, if necessary, often by the use of a wire loop with or without electric current.

To treat my condition explained to me as being:

Principal Risks and Complications of Gastrointestinal Endoscopy

Gastrointestinal endoscopy is generally a low risk procedure. However, complications are possible. You can inquire with the physician before doing the procedure regarding a discussion of risk factors. You must ask your physician if you have any unanswered questions about your test. A formal consultation can be arranged if you wish.

Perforation: Passage of the instrument may result in an injury to the gastrointestinal tract wall with possible leakage of gastrointestinal contents into the body cavity. If this occurs, surgery to close the leak and/or drain the region is usually required and may necessitate the need for a colostomy; which is a bag on your abdomen that stool would come through. Untreated, this complication could be life threatening.
Bleeding: Bleeding, if it occurs, is usually a complication of biopsy, polypectomy, dilation or banding. Management of this complication may consist only of careful observation, or may require transfusions, repeat endoscopy to stop the bleeding or possibly a surgical operation. Bleeding can be delayed for a few weeks after an endoscopy.
Medication Reactions: There are risks involved with the administration of any medicine. These risks may include mild inflammation of the vein at the injection site, nausea/vomiting, allergic reactions, impaired cardiovascular function, increase/decrease in blood pressure, breathing problems, or other complications.
Other Risks: Rarely, damage can occur to teeth or dental work when instruments are inserted through the mouth; complications from other diseases you may already have; not being able to complete the exam; and the possibility of missing a colon cancer or other lesion; instrument failure and death are extremely rare but remain remote possibilities.

You must inform your physician of all your allergies and medical problems. If you think you may be pregnant or have a major change in your medical/surgical history after your preoperative appointment, it is your responsibility to call our office.

Alternatives to Gastrointestinal Endoscopy

Although gastrointestinal endoscopy is a safe and effective means of examining the gastrointestinal tract, it is not 100 percent accurate in diagnosis. In a small percentage of cases, a failure of diagnosis or misdiagnosis may result. Other diagnostic or therapeutic procedures, such as medical treatment, x-ray type imaging and surgery are available. Another option is to choose no diagnostic studies and/or treatment. Your physician is available to discuss these options with you.

I understand that because of the sedation I may not drive or operate machinery, make critical decisions, sign legal documents or consume alcoholic beverages on the procedure day. I understand if I do not have an escort my procedure will be cancelled. I consent to the taking of photographs during my procedure to assist in my care. I am aware that my procedure report will be placed in the medical record for access by other providers for whom the information might be vital to deliver appropriate medical care. I have been fully informed of the risks and possible complications of my procedure/anesthesia and have been given the opportunity to ask questions.

I understand that unforeseen conditions may be revealed that may necessitate change or extension of the original procedure(s) or a different procedure(s) than those already explained to me. I therefore authorize and request that the physician, his/her assistants or designees may perform such procedures as necessary and desirable in the exercise of his/her professional judgement. I understand that if an untoward event were to occur, like sustaining measures will be administered. If emergency transfer to the hospital is necessary, my advanced directive, if applicable, will go into effect upon admission to the hospital. I am aware that the practice of medicine and surgery is not an exact science. I acknowledge that no guarantees have been made to me concerning the result of this procedure.

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Michelle Randolph, MD

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