alfred gastroenterology - Sydney Day Surgery

Procedure Consent Form

A form for recording pre-procedure consent

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Informed Consent Information(Required)

Please read this carefully, and take it into consideration in addition to the information that is on the website, and that has been emailed to you, and what you have discussed with the docctor.

If there is anything you do not understand, please raise this with the nursing and medical staff at the time of your procedure. We will attempt to quantify the risks of the procedure from the literature and our own experience. The risk of not having the procedure (missed cancer etc) may significantly exceed the risks from the procedure.

Gastroscopy is a generally safe and well tolerated method of examining the oesophagus, stomach and duodenum. It is usually performed with intravenous sedation following adequate preparation of the bowel. Alternative methods for examining these organs include CT scanning, MRI, barium swallow or ultrasound, however these are significantly less accurate (more likely to miss lesions such as polyps) and they do not allow for intervention such as removal of polyps if they are found.

Gastroscopy is not perfect and it is possible to miss some lesions, although the risk of missing significant lesions is quite small.

The risks associated with gastroscopy are very small and primarily related to polyp removal if it is required. These include:

1. Bleeding – 1/500. Very rarely significant bleeding can result from biopsies ~1/10 000

2. Perforation/puncture of the stomach – 1/15 000
Death due to colonoscopy – 1/25 000

3. Injury to surrounding structures (eg spleen) – very rare

4. Sedation related complications including drug allergy – very rare

5. Aspiration of stomach contents into lungs – rare

6. The rare possibility that polyps or other things may be missed, or that the procedure may be technically difficult and unable to be completed, particularly if there is poor preparation

7. A very small risk of dental damage

Colonoscopy is a generally safe and well tolerated method of examining the large intestine or colon. It is usually performed with intravenous sedation following adequate preparation of the bowel. Alternative methods for examining the bowel include CT scanning or barium enema however these are significantly less accurate (more likely to miss lesions such as polyps) and they do not allow for intervention such as removal of polyps if they are found.

Colonoscopy is not perfect and it is possible to miss polyps, although the risk of missing significant sized polyps is quite small, if you have a good bowel preparation. Polyps are present in about 50% of patients undergoing this procedure (in our experience) and, if found, are removed for histology. These are the first stage of a abnormal growth which usually goes through a “benign” phase before turning malignant.

The risks associated with colonoscopy are very small and primarily related to polyp removal. These include:

1. Bleeding – 1/500. Very rarely significant bleeding can result from biopsies ~1/10 000

2. Perforation/puncture of the bowel – 1/3000
Death due to colonoscopy – 1/25 000

3. Injury to surrounding structures (eg spleen) – very rare

4. Sedation related complications including drug allergy – very rare

5. Aspiration of stomach contents into lungs – rare

6. The rare possibility that polyps or other things may be missed, or that the procedure may be technically difficult and unable to be completed, particularly if there is poor preparation

Most complications settle spontaneously and do not require any specific intervention. Very rarely they may be life threatening and require a blood transfusion or open surgery. If you would rather not have polyps removed, or not have interventions such as a blood transfusion (in a life threatening situation), please inform the nursing and medical staff on admission. Should you have any symptoms of concern following the procedure such as abdominal pain, fever, shortness of breath, bleeding etc, please notify us immediately.

If there is a chance that you could be pregnant, or have very serious heart, lung (e.g. requiring home oxygen), kidney disease, or if you have difficulty walking up one flight of stairs without stopping, please notify us before the procedure. These issues may increase the risk of sedation.

I confirm that I have read and understood the terms outlined above.

Informed Consent Information(Required)

I confirm that I have read and understood the terms outlined above.

Informed Consent Information(Required)

I confirm that I have read and understood the terms outlined above.

Informed Consent Information(Required)

I confirm that I have read and understood the terms outlined above.

Informed Consent Information(Required)

I confirm that I have read and understood the terms outlined above.

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Procedure Consent Form

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