Hôpital Général Juif- SMBD The Sir Mortimer B. Davis Jewish General Hospital
GASTROSCOPY INFORMATION AND CONSENT FORM:
Your gastroscopy will take place on ______________________at __________ in the endoscopy laboratory located in room G-304 of the Sir Mortimer B. Davis Jewish General Hospital.
A gastroscopy is a test in which a gastroscope (a long flexible tube) is passes through the mouth and back of your throat into the upper digestive tract. It allows the physician to examine the lining of the esophagus, stomach and duodenum (the first portion of the small intestine).
During the gastroscopy, if the doctor feels a suspicious or inflamed area needs greater investigation, the doctor may take a small piece of tissue (a biopsy) to be analyzed in the laboratory. A gastroscopy is also often used to control bleeding. Many problems of the upper digestive tract, such as inflammation and gastrointestinal bleeding, cannot be diagnosed accurately by X-ray. Also, gastroscopy is more accurate in detecting ulcers and cancers than X-rays. This technique also allows for biopsies, cultures, stretching of narrowed areas, and injection of medications to stop bleeding.
Your doctor may give you medication through a vein to make you relaxed and comfortable, and your throat may be sprayed with a local anesthetic. You may be given extra oxygen through the nose. The procedure is extremely well tolerated, with little or no discomfort. You may fall asleep during or after the procedure. The tube will not interfere with your breathing. Gagging is usually prevented by the medication. Because your reflexes and judgment may be impaired by the medication you receive, it is strongly recommended that you be accompanied. You will not be able to drive for 24 hours following the procedure. After the gastroscopy, if you have received medication, you will remain in the endoscopy area until the effects of the medications have sufficiently worn off. Your throat may be sore for a few hours, and you may feel bloated for a few minutes. When you leave the department, you will be able to resume your usual diet.
For the best possible examination, your stomach must be COMPLETELY EMPTY. It is important to follow these steps: 1. If your gastroscopy is in the MORNING: FAST FROM MIDNIGHT (NO LIQUIDS OR SOLIDS) 2. If your gastroscopy is in the AFTERNOON: YOU ARE ALLOWED TO HAVE CLEAR FLUIDS (coffee, tea, juice, soft drinks, Jell-O)
FOR BREAKFAST,BEFORE 9:00AM Please remove all jewelry before the procedure. It is advisable to leave it at home, in order to avoid theft or loss. Hôpital Général Juif- SMBD The Sir Mortimer B. Davis Jewish General Hospital It is important to inform the doctor in advance if you have any of the following medical conditions:
a. If you are taking Coumadin, Aspirin, Plavix or diuretics. It is usually necessary to stop these medications ____ days prior to the procedure. Please discuss in advance with your treating physician to see if these can be stopped safely.
b. If you have diabetes: your diabetic medication will need to be adjusted prior to starting the preparation for the gastroscopy. Do not take your diabetic pills on the morning of the procedure. If you are on insulin, discuss what you should do with your diabetes doctor prior to the procedure.
c. If you are allergic to any medications, soy or eggs, notify the nurse and doctor.
Gastroscopy is associated with very low risk of complications when performed by specialized physicians. One possible complication is a minuscule perforation (a tear in the wall of your esophagus or stomach) that can occur in less than 0.01% of cases. If that were to occur, it can be managed simply with bowel rest and suctioning of fluids until the opening seals, or it may require surgery. Bleeding may occur from the site of biopsy or polyp removal. It is usually minor and stops on its own, or can be controlled by cauterization (application of electrical current), or injecting medication into the bleeding site, using a needle through the gastroscope. It is extremely rare to require transfusion, or need surgery to stop the bleeding. Another rare complication of gastroscopy is aspiration, a phenomenon by which residual stomach fluid enters the lungs after excessive gagging, causing a local irritation or pneumonia. Localized irritation of the vein or even a small bruise may occur at the site of injection of medication. This will resolve in a few days, or rarely after a few weeks. We rarely see reactions to the medication administered during the procedure. These reactions would resolve by themselves rapidly. Other extremely rare complications can occur in predisposed patients, including heart attack or a stroke. As for any other medical intervention, cases of death have been reported, but this is extremely rare. ________________________________ Referring physician Indication Informed consent: I have read and understand the content of this consent form. I agree to undergo the gastroscopy (with or without biopsy, injection, cauterization, or dilatation). ____________________________ _________________________ Patient witness ____________________________ _________________________ Date doctor’s signature