Dr K Farahat Gastro-enterology Brussels, / / 2015

Transcription

1 MEDICIS Avenue de Tervueren, Bruxelles Tél: Dr K Farahat Gastro-enterology Brussels, / / 2015 Concerns : Name : First name : Birthday : Address : Dear Madam, Dear Sir, Your medical doctor has recommended a colonoscopy / gastroscopy. This exam could be performed on...at... o'clock Please bring your identity card and 5 vignettes of your insurance company on arrival. Please find the required information concerning the exam, the fiber free diet list, preparation for the colonoscopy and the informed consent form to be signed. If the examination is carried out under anesthesia, a health questionnaire is to be completed. Thank you for your cooperation. Dr K Farahat Gastroenterologist

2 INFORMED CONSENT I, undersigned... certify that I have read and understood the information concerning the examination, the indication, the practical modalities, the potential complications and recommendations following the completion of colonoscopy. Before the exam, I have had the opportunity to discuss with my physician/gastroenterologist. Read and approved Date. Signature

3 Health Questionnaire Thank you for answering this questionnaire for a better assessment of your physical condition and to take all the necessary measures for a safe procedure and anesthesia. Name : First name : Age : Weight : Height : Smoking?.Alcohol? occasional or regular Allergies? yes no Allergies to medications : Easy bruising ou nasal bleeding? Diabetes? yes no Hypertension? Yes no Glaucoma? yes no Heart problems? Stenting (coranary or vascular)? Pacemaker? yes no Difficulty in breathing? Asthma, chronic bronchitis or emphysema? yes no Renal insufficiency? yes no Neurological disease? Surgical intervention? Past history of problems during anesthesia? Hip or knee replacement? Transmitted disease (HIV, Hepatite B/C)? Questions to be addresed to the anesthesiologist? - - Thank you for your cooperation.

4 INFORMATIONS CONCERNING COLONOSCOPY Colonoscopy aim to visualize the interior of the large intestine (colon) using a flexible endoscope introduced through the anus. Colonoscopy is used to look for any anomalies of the colon, take samples and to remove polyps (abnormal growth of the mucosa which can lead to cancer). The quality of the examination depends on the quality of your preparation which consists of a fiber-free diet and taking laxative. The stool should be clear (similar to urine) to perform the examination in optimal conditions. Colonoscopy takes about thirty minutes. If it is done under anesthesia, please allow an additionnal small period of recovery and monitoring. Examination could be performed with or without anesthesia and in this latter case, the administration of a sedative is possible to make the colonoscopy as comfortable as possible. In all cases, it is recommended to be accompanied back home. It is forbidden to drive after the examination or to perform tasks which require concentration. After the examination, abdominal cramps may occur. They will be relieved by the emission of air that has been put during the colonoscopy. The left lateral position, flexed legs and abdominal massage help to release the winds. Precautions are taken to reduce major complications (less than 3 per 1000 colonoscopy) as bowel perforation or significant bleeding. In case of major complications, hospitalisation for medical or surgical treatment may be necessary. It is recommended to tell the doctor about your health status (allergies, diabetes, cardiovascular stent, relevant cardiopulmonary history) or if you take any anticoagulation therapy. In case of anti-platelets drugs intake (Plavix, Ticlid...), it's mandatory to stop them for a week before the colonoscopy and to replace them with aspirin. In case of anti-vitamin K treatment (Sintrom, Marcoumar, Pradaxa, Xarelto...), you have to stop them for 5 days before the examination and to replace them with a low molecular weight heparin subcutaneously (Clexane, Fraxodi, Fraxiparin...). Injection has to be stopped 24 hours before colonoscopy. Cardiologist / anesthesist opinion is mandatory. The signed informed consent form has to be submitted just before the colonoscopy. Dr. K Farahat (mobile: klfarahat@hotmail.com) is available for any additional information concerning your colonoscopy.

5 Instructions to be followed for performing colonoscopy UNDER anesthesia Date of examination: Time: Free-fiber diet for 4 days before the colonoscopy (starting from / ) The day before the examination : Take 2 tablets of Dulcolax (Bisacodyl) at 2 pm. Snack at 4 pm. If your colonoscopy is sheduled early morning (before 10 am), drink 2L of Moviprep followed by 1L of water from 7-10 pm (3 L in total to be taken in 3 hours). If your colonoscopy is scheduled late morning (after 10 am), drink 1L of Moviprep followed by 1L of water from 7-9 pm (2 L in total to be taken in 2 hours) and the remaining 1L of Moviprep followed by 1L of water should be taken the day of the examination from 6-8 am (2 L in total to be taken in 2 hours). The day of the examination : If your colonoscopy is scheduled early in the morning, remain fasting (no eat or drink). If your examination is scheduled late in the morning (after 10 am), you are allowed to drink until 2-3 hours before the examination. No food allowed.

6 Fiber Free Diet List List of foods allowed to be consumed during the 4 days of fiber-free diet: White bread and crackers made with white flour or cornstarch. The following cereals: Rice crispies, Choco Pops, Corn Flakes. Jam jelly, chocolate, honey, butter. White rice and white pasta. Potatoes, nature or mashed. Fish, poultry, eggs. Dairy products (with no fruit), cheese, yogurt, pudding. Biscuits and waffles. Water, tea, coffee, herbal teas, milk, cocoa, juices without pulp and no sparkling (flat) drinks.