Download File #: Information on Preparing for a Colonoscopy Last Name: First

File :
Last Name:
First Name:
NAM :
Information on Preparing for a Colonoscopy
General and Specialized Physical Health Program
Date of Birth :
Exp.: 20 ___/_
_____ /_
year
month
/ ___ M
day
F
POSSIBLE COMPLICATIONS ASSOCIATED WITH A COLONOSCOPY
Colonoscopies and polyp removal are safe procedures. There can, however, be complications.
 Bleeding: Bleeding may occur after a biopsy or polyp removal (1 or 2 possible cases/100). Bleeding will generally be
mild and stop on its own. Heavy bleeding is rare. It if does occur, cauterization may be used.
 Infections: All instruments used in diagnostic and therapeutic digestive endoscopy must undergo high-level disinfection.
Digestive endoscopes are subject to reprocessing procedures that control the risk of infections.
 Side effects, respiratory depression and allergic reactions to the drugs used: These may occur. The procedure may
involve the use of medications (a sedative and/or analgesic). If this is the case, make sure you tell the nurse or doctor if you
have had any drug reactions in the past.
 Perforation of the colon: This risk is very rare (1 possible case/1000). Research has shown a very low risk
of colon perforation, particularly for a first -time colonoscopy.
 Other complications: Other complications may occur based on your medical history. Make sure you tell the nurse or doctor
about your medical and surgical history.
INSTRUCTIONS:
Please read the information below and mark an “X” in the once you have done so:

I have read and understood the possible complications listed above.
Please read the information below and mark an “X” in one of the two once you have done so:
 I agree to the procedure without a prior consultation with the medical specialist. I understand, however, that on the day of the
procedure, I will have the chance to speak with the colonoscopy specialist regarding possible risks and complications.
 I wish to consult with the medical specialist before the procedure and I understand that this request will lead to additional wait
time. I agree to fully complete this form and fax it to the endoscopy department as soon as possible: 450-975-5036. Please
make sure you have filled out all the information in the right-hand corner of the form and signed and dated the document.
Signature of user or legal representative
year
/
/
month
day
Please hand in this form at the endoscopy reception desk on the day of the procedure so it may
be added to your file.
68-000-660
Date: 2015-12-02
MEDICAL FILE
INFORMATION ON PREPARING FOR A COLONOSCOPY
1 of 1
TOTAL COLONOSCOPY
Your doctor has requested an endoscopic procedure for you. Endoscopy is a medical
specialty that involves examining the inside of the body using flexible tubes equipped
with a light. The procedure is used to take samples, which is painless, and to have
these sent to a laboratory for analysis.
WHAT IS A TOTAL COLONOSCOPY?
A colonoscopy is an exam of the lower digestive system (colon) using a colonoscope.
A colonoscope is a flexible tube no thicker than a finger. It is inserted into the colon through the
rectum until it reaches the caecum, where the doctor can carefully examine the lining of the colon.
The doctor is then able to confirm and closely study anomalies previously seen on X-rays or detect
anomalies that are too small to be seen on X-rays.
If the doctor sees something abnormal or wishes to analyse more closely any inflammation or
part of the colon, he or she can insert forceps in the colonoscope to take a tissue sample (a
biopsy) of the colon lining in order to have it analyzed in a laboratory and establish a
diagnosis. The doctor can also use a small brush to collect cells for laboratory analysis or a
cutting instrument that uses heat to remove polyps (small, benign tumours on the inner lining
of the colon).
HOW DO I PREPARE FOR MY COLONOSCOPY?
Here are instructions to follow for best results:







You will need to empty your colon of stool by taking a special colon-clearing preparation
prescribed to you by your doctor.
Let the doctor know all medications you are taking. Ask if you need to stop taking them
and, if so, for how long.
Tell your doctor if you have any drug allergies, if you are taking anticoagulants (coumadin,
pradax, xarelto, eliquis, effient, brilinta, ticlid…), anti-inflammatories, aspirin, plavix, iron,
etc. if you wear a pacemaker or if you have diabetes.
Bring your list of medications.
You will be given medication for the procedure and you will not be able to drive after. You
must be accompanied after your colonoscopy or your appointment could be cancelled.
Do not wear jewellery and bring only a small amount of money.
For your comfort, bring a bathrobe and slippers.
WHAT HAPPENS DURING THE PROCEDURE?
As you lie comfortably on your left side, you will be given an intravenous drug (a sedative) to
help you relax and make you feel drowsy.
The doctor will insert the colonoscope into your rectum and slowly advance it through your
colon until it reaches the caecum. Air will be passed into the colon to allow a clearer view.
Then, the colonoscope will slowly be withdrawn, as the doctor continues to carefully examine
the lining of the colon.
The test is generally well tolerated. It causes cramps or abdominal discomfort, which are
usually mild to moderate. The procedure lasts approximately 30 minutes.
WHAT HAPPENS AFTER THE PROCEDURE?
You will remain under observation until the effects of the medication have almost completely
worn off – about 30 minutes.
You may feel bloated for a few minutes or even a few hours due to the air that was pumped
into your colon.
Unless indicated otherwise, you can eat and drink normally after the procedure.
You are not allowed to drive for 24 hours after the procedure, since the medication you
received can impair your judgement and reflexes.
Complications from colonoscopies are rare and most often occur during the
procedure. If complications do arise, they are primarily associated with the sedation
(cardiopulmonary problems in 5/1000 cases), post-polypectomy bleeding (1-2/1000
cases) or perforations (1/1000 cases). They can require emergency surgery to repair a
tear or a hospital stay for observation. If you develop fever (>38.0oC/100.4oF), chills,
abdominal pain, chest pain or red blood in your stool, notify your doctor immediately.
Otherwise, go straight to the emergency room.
If you have any questions, speak with your doctor or a health care professional in endoscopy.
If you are unable to make it to your appointment, please advise
the endoscopy department as soon as possible by calling (450)
975-5400, ext. #3
CISSS de Laval
Endoscopy
Department
Open Monday to Friday from 8 am to 4 pm
Phone: (450) 975-5400
SEDATION/ANALGESIA
What is sedation/analgesia?
You were given medication to help you relax, make you drowsy and alleviate discomfort
associated with a procedure. This is known as sedation/analgesia. The sedation effect is
due to a sedative, which reduces anxiety, while the analgesic effect is provided by an
opioid analgesic, which eases any pain caused by the procedure.
Examples of sedatives: Ativan®, propofol, ketamine, nitrous oxide, midazolam, etc.
Examples of analgesics: Morphine, Demerol®, Dilaudid®, fentanyl, etc.
Sedation/analgesia side effects
Most people experience very few side effects after sedation/analgesia. The following effects
have, however, been noted within 12 hours of receiving it: difficulty staying awake
(drowsiness), concentration problems, dizziness, sensation of unsteadiness, drop in blood
pressure, nausea, vomiting, mild confusion and disorganized thinking.
.
Precautions to be taken by adults 24 hours after undergoing sedation/analgesia
 Avoid activities that require alertness, concentration or coordination.
 Do not operate a car or any other vehicle.
 Do not do sports.
 Have someone you trust keep an eye on you.
 Postpone signing any contracts or major purchases.
 Do not drink alcohol.
 Take only the medication prescribed by your doctor and follow the dosage.
For more information, call 811 any time to speak with an Info-Santé nurse
You must be able to be woken up easily.
If you go into very deep sleep, if you snore loudly and if you are not waking up, someone must call
911 and continue to try to wake you up as you wait for emergency assistance.
CISSS de Laval, Endoscopy Department Phone: (450) 975-5400
YOUR COLONOSCOPY APPOINTMENT
Bi-PEGLYTE
Date: ________________Time: _________________
Doctor’s Name: ____________________________
Patient’s Name: _______________________________
To facilitate access to endoscopic
Tel: _______________________________________
examinations, we require that you
call us at least 5 days in advance TO
POSTPONE YOUR APPOINTMENT at Drugstore’s Name: _________________________________
this number (450) 975-5400 poste #3.
Tel: __________________Fax: ______________________
This will enable someone else to
have their test.
Hôpital de la Cité-de-la-Santé
Service Endoscopie
1755, Boul. René-Laennec, Laval, H7M 3L9
What is a colonoscopy?
A colonoscopy is a procedure in which a doctor examines the colon to detect any inflammation,
polyps or cancer.
What takes place during the examination?
A colonoscope is a flexible tube the width of a finger that is equipped with a camera. It is inserted through the
anus and gradually advanced through the entire colon up to the cecum.
To ensure good visualization of all the walls of the colon, CO2 is injected into the intestine. This can cause cramps
or a bloating feeling during the test.
To reduce the discomfort associated with the procedure, you will be given drugs intravenously to help you relax
and make you drowsy. The examination takes about 20 minutes.
What happens after the examination?
After the examination, you will be kept under observation until the effects of the medications have almost completely worn off (about 30 minutes).
What are the potential complications?
A colonoscopy is a safe procedure with very low risks when performed by a qualified physician. However, there
are certain potential complications:
— Bleeding < 1/100 – 200
— Perforation < 1/1,000 – 2,000
— Infections
— Side effects, respiratory depression, or allergies to medication
— Other complication due to your medical history
If medication is needed for your examination,
YOU CAN NOT DRIVE A MOTOR VEHICULE
for 24 hours, consequently a responsible adult
should be present during the procedure and
accompany you home afterwards.
What you need to bring on the day of the examination?
— Slippers and dressing gown
— A complete list of all your medications, as provided by your
pharmacist
— Your health insurance card and hospital card
— Leave any jewelry, piercing jewelry or any other valuables at home
ENSURING THE QUALITY OF YOUR EXAMINATION
A) Diet
FOODS TO BE AVOIDED DURING THE 3 DAYS PRECEDING THE TEST:
— Bread, multigrain pasta, cereals and brown rice (fibres);
— Beans and legumes (red beans, lentils, chick peas, dry peas, etc);
— Seeds and nuts;
— Fruits with small seeds (strawberries, raspberries, kiwis, watermelon, blackberries,
grapes, tomatoes);
— Chips, popcorn and coconut;
— Corn;
— Ensure.
ALLOWED LIQUIDS
LIQUIDS TO BE AVOIDED
— NO red or violet beverages
— NO alcoholic beverages
— NO milk or dairy substitutes
— NO liquids that you can’t see through
* Avoid all dairy products (milk or cream) and
substitutes (almond milk and soya milk).
— Water or ice;
—
—
—
—
—
Clear juice without pulp (apple, white grape or lemonade);
Jell-O and popsicles (except red or purple);
Beef or chicken consommé or broth (without noodles or
vegetables and with no solid residue);
Herbal tea, tea or coffee (without cream, milk or milk substitute);
Clear soft drinks (Sprite, 7-Up or ginger ale).
ON THE DAY BEFORE YOUR COLONOSCOPY
B) Preparation
IN THE MORNING
STEP
1. You can have breakfast before 8 AM. After that you will be on a liquid diet
2. Prepare the Bi-PegLyte solution as follows:
a) Pour contents of 1 full pouch into 1 litre of water (32 ounces);
b) Stir for 2 or 3 minutes until the solution is clear.
Repeat steps a) and b) with the second pouch.
Store both solutions in the refrigerator to improve the taste.
STEP
IN THE AFTERNOON
1
2
3
STEP
Take the 3 bisacodyl tablets with water around 3 p.m..
Do not chew or crush the tablets. No antacids are allowed for one hour after taking the
bisacodyl tablets.
IN THE EVENING
At around 7 p.m.: Quickly drink 1 glass of the first solution (about 250 mL) every 10 minutes
until you have finished the entire litre of solution (4 glasses in all).
Check each glass after drinking it
ON THE DAY OF THE COLONOSCOPY (Clear liquids are allowed with 2 hours before your appointment)
STEPE
4
4 hours before your appointment: Quickly drink 1 glass of the second Bi-PegLyte solution
(about 250 mL) every 10 minutes until you have finished the entire litre of solution
(4 glasses in all).
Check each glass after drinking it
Abdominal bloating or distention may occur before your first bowel movement. If the discomfort persists, temporarily stop drinking the Bi-PegLyte
solution or drink each portion of 240 mL at longer intervals (more than 10 minutes) until the symptoms disappear.
If you experience severe bloating, distention or abdominal pain, administration of the solution should be slowed or temporarily discontinued until the
symptoms abate. Report these events to your physician.
To clean thoroughly your bowel, we recommand that you drink additional liquids during the Bi-Peglyte preparation.
Approved by: Dr Carmine, Nudo gastroenterologist and Dr Patrick Montpetit, surgeon, October 2016
DM1703
Precautions: