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Information on colonoscopy Treatment we propose you demands your written consent. To allow you this decision, this leaflet and a possible explaining conversation inform you on the type, healing importance and possible complications of the planned treatment. Why do we propose you such treatment? Based upon so far performed examinations and medical interview we suspect the existence of illness changes within large intestine. For correct determination of these changes or exclusion thereof before possible therapy, diagnostic examinations shall be made. There are two examination methods: (1) endoscope assessment of large intestine or (2) radiologic method with the application of a contrast agent rectally introduced. The application of endoscope technic mostly do not result in any pain or there is only a little pain and the assessment of the intestine is much more precise than in RTG examination. It eliminates also the possibility of skipping illness changes to much extent. In major cases, it does not demand general anesthesia. The possibility of associating the diagnostic examination (colonoscopy) with possible simultaneous therapeutic treatment, (i.e. removing polyps) in case of such a change, is also not without significance; which is impossible in the RTG examination. Performing examination The examination is performed after respective preparation, providing cleaning the intestine from leftover food mostly by orally administered laxatives, supported by infusions or rectal ingots. Preparation starts a day before the intervention, when a patient is not allow to eat and to drink other liquids than those devoted for intestine cleaning. In rare cases, due to general health condition of a patient, cleaning intestine provides some days long starvation diet connected with several rectal cleaning ingots. The examination as such is performed with the application of a flexible colonoscope entered to the large intestine through anus. The intervention may be periodically painful: possible pain shall be distinguished from permanently occurring bulge resulting from administering air to the intestine light for its full assessment) shall be notified to the doctor and its permanent persistence may be indication to resign from further assessment of the intestine. The instrument for colonoscopy is specially disinfected before each examination; thus, infection is practically impossible. If needed, sections for histopathologic assessment are taken from illness changes with the use of sterile tongs which also protects against infection. Possible complications No physician can warrant the successfulness of the examination and full safety. Complications occur very rarely (0,35%). They are: perforation of the wall of the digestive tract (0,14-0,18%), bleeding (0,008%), that usually demand immediate surgery. Single cases of reflex cardiac arrest were described, too. The mortality for these reasons is even rarer. Though complications occur extremely rare it is very important for patients to pay attention to alarming symptoms after examination: strong stomach pain, anus bleeding (small bleeding may occur after the intervention and it is a normal phenomenon), fever, shivers. In such a situation you shall contact your doctor or visit the nearest hospital (Emergency Room or SOR). Complications may usually occur up to 14 days after intervention. To mitigate the bleeding danger and intestine perforation and to decrease risk associated with administration of anesthetics, please answer following questions; 1. Have you increased ability to bleeding, especially after small cuts, after teeth removing, or formation of bruises after small mechanical injuries? Yes No 2. Did such symptoms occur among your relatives? Yes No 3. Did you have any allergy symptoms to food or medicaments? Yes No 4. 4. Do you take any medicaments affecting the blood clotting (i.e. aspirin, dicumarol, etc)? Yes No Conducting after examination In case of the application of anesthesia, you are not allowed to drink or to eat for 2 hours after treatment. Also occurrence of other you unclear symptoms shall be immediately notified to a nurse of physician. Please ask if you did not understand everything, or if you want to know more about this examination, or other diagnostic methods, mentioned complications or other bothering problems associated with the proposed treatment. I got acquainted with above mentioned information concerning the intervention. …………………………………………………………………. Surname and name of the patient or its guardian: Date and signature................................................... Certified to be true and faithful translation of the document presented to me today, 2 nd January 2017 Beata Mossakowska- Panek, sworn translator of the City of Warsaw Reg. No: 9/2017 Version_V 3 dated 15.11.2016