Download Colonoscopy Informed Consent

Colonoscopy Informed Consent
(Please be sure to read both sides)
You and your doctor are considering a procedure called colonoscopy, which is the examination of your colon
with a flexible, lighted scope. This procedure is most often done for:



colon cancer screening,
follow up and removal of polyps (abnormal growths), and
investigation and possible treatment of anemia, bleeding, diarrhea or other bowel problems.
During the colonoscopy, various procedures to aid in diagnosis or treatment may be performed:



A biopsy, which is a small tissue sample about the size of a match head, may be taken.
If a polyp is noted, Dr. Zachary may choose to remove it using a small instrument that is passed through
the scope. If a polyp is too large to be removed or if cancer is suspected, the site can be “tattooed” by
injecting sterile ink or carbon. This is an aid for future follow up or for surgical resection of the polyp.
The removal of polyps has been shown to greatly reduce the risk of developing colon cancer.
Abnormal bleeding may be treated with cauterization, injection of constricting medicines, metal clips or
rubber bands.
Colonoscopy performed by specially trained and experienced gastroenterologists is generally a very safe
procedure, but, like any medical procedure does carry some possible risks:





Major complications such as bleeding or perforation (making a hole or tear in the colon) occur in less
than 3 out of 1000 colonoscopy procedures and may require surgery. Bleeding and perforation are
more likely when large polyps are removed.
Bleeding may occur even several days after polyp removal and is more likely to occur if you take
certain medications that thin the blood: Coumadin (warfarin), Eliquis (apixaban), Pradaxa (dabigatran),
Xarelto (rivaroxaban), Lovenox (enoxaparin), Arixtra (fondaparinux), heparin, Plavix (clopidogrel),
Brilinta (ticagrelor), Effient (prasugrel) aspirin products, or arthritis medications. Be sure to discuss
with Dr. Zachary or his staff what to do if you take any of these medications.
Reactions to the sedative medications given during the procedure may occur, although this is
uncommon. Please notify Dr. Zachary or his staff if you have any medication allergies or previous
unusual reactions to sedatives. Also, you can undergo the procedure without sedation. Be sure to
notify Dr. Zachary if you prefer no sedation.
Very rarely, there can be unforeseen complications that include breathing or heart problems, infection,
injury to other internal abdominal organs, or even death.
Sometimes it is not possible to examine the entire colon and additional testing may be required. It is
also possible to miss polyps or cancer. The reported miss rates for polyps may be up to 6-12% and for
cancer up to 5%. The miss rate appears to be smaller when colonoscopy is done by specially trained
and experienced gastroenterologists.
Depending on the reason for your colonoscopy, you should also know that there may be potential risks to not
doing the procedure, such as delayed diagnosis of cancer or missed diagnosis of disease.
There are alternatives to colonoscopy:
 Two radiologic alternatives for viewing the colon are barium enema and colonography with either CT
or MRI (“virtual colonoscopy”). If abnormalities are found on either of these tests, a colonoscopy may
be required for further investigation.
 Alternatives to colonoscopy for cancer screening include fecal occult blood testing (testing the stool for
hidden blood), stool based DNA tests (looking for abnormal genetic changes of cancer cells excreted in
the stool), and flexible sigmoidoscopy (looking at the lower 60 cm of the colon with a lighted scope). If
abnormalities are found on any of these tests, a colonoscopy may be required for further investigation.
 Polyps and bleeding can be treated with surgery.
 Sometimes bleeding can be treated with a radiologic procedure.
The day before your procedure you will need to make a change in your diet and take a laxative preparation (see
separate instructions).
If you desire to have a more thorough explanation of the procedure or have more questions regarding the
procedure, please have your referring physician arrange a consultation on a separate day from the procedure to
have a detailed discussion with Dr. Zachary or his staff.
By signing this consent form, I acknowledge that I have read and understand what is involved in a colonoscopy
procedure; including the benefits, risks, and alternatives to colonoscopy; and I agree to proceed with the
colonoscopy.
Signature of patient/responsible party
Date/Time
Name Printed
To the best of my knowledge, the patient has been adequately informed and has consented.
Physician signature
Date/Time