Download EGD Informed Consent

Upper Endoscopy Informed Consent
(Please be sure to read both sides)
You and your doctor are considering a procedure called upper endoscopy, which is the examination of your
esophagus (food pipe), stomach, and duodenum (first part of the small intestine) with a flexible, lighted scope.
This procedure is most often done for:
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upper abdominal pain or discomfort
gastroesophageal reflux disease (acid reflux or heartburn)
difficulty swallowing
persistent nausea and vomiting
bleeding from the upper gastrointestinal tract
unexplained anemia or weight loss
follow up of previous abnormal findings, such as Barrett’s esophagus (a precancerous condition), ulcers
or polyps
further investigation of abnormalities found on X-ray studies, such as an upper GI or CT scan.
During the upper endoscopy, various procedures to aid in diagnosis or treatment may be performed:
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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.
Abnormal bleeding may be treated with cauterization, injection of constricting medicines, metal clips or
rubber bands.
Strictures (narrowed areas) may be dilated (stretched) with balloons or tapered tubes.
A pH probe can be placed to determine amount of acid reflux and correlate symptoms with acid reflux.
Ingested foreign objects may be removed with a variety of small instruments passed through the scope.
Feeding tubes can be placed for long term nutritional support.
Upper endoscopy performed by specially trained and experienced gastroenterologists is generally a very safe
procedure, but, like any medical procedure, does carry some possible risks:
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Major complications such as bleeding or perforation (making a hole or tear in the upper gastrointestinal
tract) occur in less than 3 out of 10,000 upper endoscopy procedures and may require surgery.
Bleeding and perforation are more likely when large polyps are removed, dilation is performed (less
than 4 out of 1000 dilations), foreign objects are removed, or feeding tubes are placed.
Bleeding may be 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.
Uncommonly, aspiration (inhaling food or liquids into the lungs) can occur, possibly causing
pneumonia or difficulty breathing. The risk of aspiration can be minimized by not eating or drinking
before the procedure. (See separate instructions)
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.
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Very rarely, there can be unforeseen complications that include breathing or heart problems, infection,
damage to teeth or dental work, injury to other internal abdominal organs, or even death.
Sometimes it is not possible to examine the entire upper gastrointestinal tract and additional testing
may be required. It is also possible to miss cancer, although this is rare.
Depending on the reason for your upper endoscopy, 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 upper endoscopy:
 The upper gastrointestinal tract can be examined with a barium upper GI X-ray examination. If
abnormalities are found, an upper endoscopy may be required for further investigation.
 Polyps, bleeding and strictures can be treated with surgery. Foreign objects may be removed and
feeding tubes may be placed surgically.
 Sometimes bleeding can be treated and feeding tubes can be placed with a radiologic procedure.
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 an upper
endoscopy procedure; including the benefits, risks, and alternatives to upper endoscopy; and I agree to proceed
with the upper endoscopy.
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