Having a Colonoscopy (Diagnostic)

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1 Having a Colonoscopy (Diagnostic) Patient Information Important Please read now Ninewells Hospital Telephone: Perth Royal infirmary Telephone: Stracathro Hospital Telephone: Please read this booklet and complete the enclosed health questionnaire and the consent form in the middle of the booklet before you arrive. Introduction Your doctor has arranged for you to have a colonoscopy. This booklet aims to give you enough information: To give properly informed consent for the procedure To help prepare you for the procedure To guide you through the procedure To make appropriate arrangements afterwards To answer frequently asked questions What is a colonoscopy? A colonoscopy allows direct inspection of the large bowel (rectum and colon). A slim flexible tube with a bright light at the end (a colonoscope) is passed through your anus into the rectum, and guided gradually around the colon and into the end of the small intestine. Instruments can be passed through the colonoscope to allow samples to be taken and other procedures to be carried out. The appearance of your intestine may be recorded on a photograph or video film for future reference. When and where does the colonoscopy take place? Your appointment is given in the letter you received with this booklet (directions to the Unit are in the letter). Please check which hospital you are being asked to attend. Page 1 of 14

2 If you wish to change the appointment, please telephone the number on your appointment letter (an answerphone is available out of hours). If you cannot attend the appointment you must notify us as early as possible, so the appointment will not be lost. If you fail to attend the appointment and do not make contact within 5 days of the appointment your request card may be returned to the doctor who asked for the procedure. This means that you will not be given another appointment. If you need Patient Transport, please telephone to arrange this. As a patient, you deserve privacy and to be treated with dignity and respect in a way which takes account of your physical, communication and cultural needs. Treating all our patients in privacy and with dignity is our priority, to ensure your experience is the best it can be. Our Endoscopy Unit provides treatment to both male and female patients as part of an outpatient service. We are working to the principle of providing separate (single sex) accommodation, where possible, for patients during their journey through our endoscopy service. We are also committed to providing separate areas for patients waiting to have their procedure, from those patients who are recovering from a procedure. Where we are not able to provide care in a single sex area we will: ask you to bring a dressing gown use privacy screens ask you to take your bowel preparation at home, if appropriate If you are uncomfortable with being treated in a mixed sex environment then please discuss this with a member of staff prior to your appointment. We will, where practical, take your needs and preferences into account. If you have a pacemaker or ICD (Implantable Cardioverter Defibrillator) please contact the department where you are having your test for further advice. How long does the colonoscopy take? Colonoscopies are performed in a morning or afternoon session. You should attend at the appointed time; this is to allow time for the admission and assessment process, so you may not have the colonoscopy immediately. The colonoscopy takes from 20 minutes up to 45 minutes but may take longer. You will probably be in the department for 2 to 3 hours. You should bring your own dressing gown and slippers. You are also welcome to bring your own reading or listening material (for example books, magazines, ipods). How do I prepare for colonoscopy? If you are pregnant or think you may be pregnant contact the Endoscopy Unit. Some people have sedation for a colonoscopy. You must arrange for a responsible relative or friend to drive you home or accompany you on public transport and it is advisable to have someone with you for at least 12 hours after the procedure. This person should come with you to the Unit so that they know where and when to collect you afterwards. You should make these arrangements well before your appointment. Page 2 of 14

3 Your procedure may not be performed if you have not made these arrangements. Some people have Entonox for a colonoscopy. Entonox is a pain relieving gas. This is a mixture of gases, oxygen and nitrous oxide. It is designed to give pain relief without causing too much sleepiness. You might have heard of this before as it is commonly used for pain during childbirth. Entonox works very quickly, wears off quickly and has few harmful effects. For this reason it can be given during colonoscopy. How does Entonox work? Entonox is designed for you to be able to breathe it in yourself. The gas can only be obtained by you inhaling from a mouthpiece or facemask. As soon as you remove the mouthpiece/mask from your mouth or face the gas flow stops. Your nurse will be able to show you the equipment and let you practice holding it before you have your test. How quickly does it work? The gas works quite quickly. It will start to work within one or two breaths and is working fully in one or two minutes. You can start breathing the gas as soon as the procedure begins so that you can gain maximum effect if the procedure becomes uncomfortable. You can start and stop any time you want to. While taking Entonox The gas will help ease any discomfort. It is cool and pleasant and has a sweetish taste. The mouthpiece or mask must form an effective seal in the mouth or on the face before you breathe in or the dose you get will be less. The nurse will supervise you until you get used to this. The mouthpiece or mask is left in place while you breathe out. It is important that you breathe slowly but deeply. Side effects Entonox can make you feel drowsy but you will still be able to ask or answer questions. You will be able to obey commands, for example, change your position during the test. Entonox can make you nauseated, light headed or give you a dry mouth. This does not always occur, but if it does, stop breathing the gas and the feelings will go away almost immediately. Entonox can also make you feel very happy. This is why it is sometimes called laughing gas. Whilst this is not an unpleasant effect, some people may feel embarrassed. This effect also wears off very quickly after stopping inhaling the gas. After care Entonox has no real long lasting effects when used for a short period of time. You will be monitored in the recovery area for at least 30 minutes after the test. Once you are assessed medically fit to be discharged you will be able to drive and return to your normal activities. You will also be able to go home without an escort. Page 3 of 14

4 You will not be suitable to use Entonox if you have had: COPD or any severe lung problems undergone a recent dive within the last 48 hours any head injuries recent eye surgery for retinal detachment abdominal distension bowel obstruction middle ear problems or you are in your first 16 weeks of pregnancy Important information: If you are not suitable to have Entonox and decide to have sedation during the colonoscopy, you will have to organise an escort to collect you and stay with you for 24 hours. You cannot drive home alone. If you need further advice you can phone the Unit where you are having your test, or your GP. If you have: diabetes take Clopidogrel take Warfarin have Addison s disease please see the specific instructions on the next page. What if I have diabetes? We will give you an early appointment if we are told you have diabetes. If you have been given a late morning or afternoon appointment, please telephone the Unit. Important information for people who have diabetes prior to a procedure Preparation prior to procedures such as bowel preparation medicine, the type of food and drink allowed, and, fasting for a procedure can potentially cause your blood sugar levels to be low. The guidelines on the next page will help you reduce the risk of problems. If you have diabetes treated with tablets: Ask for an early morning appointment for your procedure, before 10am. If you take tablets Gliclazide, Glipizide, Glimerpiride or Glibenclamide for diabetes the dose can be reduced by 50% (by half) during the day of bowel preparation treatment. On the morning of your procedure, do not take your tablets for diabetes. Bring your diabetes tablets with you to your appointment. You can take your diabetes tablets as prescribed with food following the procedure. Page 4 of 14

5 If you have diabetes treated with insulin: Ask for an early morning appointment for your procedure, before 10am. The dose of your mealtime insulin can be reduced by 30 50% (one third to one half) during the day of bowel preparation treatment. If you normally take insulin before each main meal and long acting insulin once daily, continue to take your long acting insulin as usual, daily (Lantus, Levemir, Insulatard, Humulin I). On the morning of your procedure, do not take your mealtime breakfast insulin. Bring your insulin with you to your appointment. You can take your insulin as prescribed with food following the procedure. If you are restarting your insulin late in the morning or before lunchtime then it is advisable to take half of your normal breakfast insulin dose at this late time. If you have any doubt about managing or adjusting your diabetes medicine before your procedure, please contact your diabetes healthcare professional or the Diabetes Specialist Nurses on the telephone contact number below. Diabetes Specialist Nurse Contact details: Monday Friday, 9am 5pm Ninewells Hospital Telephone: Perth Royal Infirmary Telephone: Further details: Remember: A change in your normal diabetes medication and food routine may affect your blood sugar levels and so it is advisable to have someone accompany you to and from hospital (you are not advised to drive yourself). What if I take Warfarin, Clopidogrel, Plavix and/or Aspirin? If you are on Clopidogrel/Plavix, Warfarin or Aspirin, continue to take these. Do not stop your Warfarin tablets. Continue on your present regime but 7 days before your appointment; arrange to have your Warfarin level checked at your Warfarin Clinic or GP Surgery. This is to make sure it is at the correct level, if it is not, you will be asked to adjust your dose prior to your appointment. Your GP will organise this with you. Please bring your INR record book with you to your appointment. What if I take Rivaroxaban (Xarelto, Dabigatran (Pradax) or Apixaban? These new blood thinning tablets should be omitted on the day of the procedure. What if I have Addison s disease? If you have Addison s disease, please let us know so that other arrangements can be made for you. Page 5 of 14

6 How and why do I take the Bowel Preparation? It is essential that your bowel is completely empty on the day of the procedure, so that the endoscopist can get a complete view unhampered by faeces. If you have a stoma, please telephone the department to check if you need to take any bowel preparation. Preparations for this need to start well beforehand, so it is important that you follow the instructions for your diet and take all of the bowel preparation, otherwise the procedure may need to be repeated. 7 days before the appointment: Stop taking any iron supplements or medicines that contain iron. Stop or reduce, if possible, painkillers containing codeine or dihydrocodeine. Paracetamol can be used as an alternative. Stop anti-diarrhoea medication for example Loperamide, Codeine Phosphate, Imodium, Lomotil, or stool bulking agents for example Fybogel, Regulan, Proctofibe. Stop eating seeded breads The day before: Follow the bowel prep instructions in this leaflet rather than the manufacturer s instructions as these differ slightly. You should remain at home, take the enclosed MoviPrep or Klean-Prep purgative and take a clear fluid diet, as follows: MoviPrep instructions Morning appointments the day before: Start a clear fluid diet after a normal breakfast. Do not eat anything solid after 9am. At 4pm make up the first litre (1000mls) of MoviPrep (sachets A and B) and drink over 1 hour. Have a rest for 2 hours. It is important to drink an additional 500mls of water or clear fluid with each litre of MoviPrep during the evening. At 7pm make up the second litre of MoviPrep (sachets A and B) and drink it over 1 hour. It is important to drink an additional 500mls of water or clear fluid with each litre of MoviPrep during the evening. Afternoon appointments the day before: Start a clear fluid diet after a light lunch. Do not eat anything solid after 1pm Page 6 of 14

7 At 6pm make up the first litre (1000mls) of MoviPrep (sachets A and B) and drink over 1-2 hours It is important to drink an additional 500mls of water or clear fluid with each litre of MoviPrep during the evening. The day of your examination: At 7am make up the second litre (1000mls) of MoviPrep (sachets A and B) and drink it over 1 2 hours. It is important to drink an additional 500mls of water or clear fluid with each litre of MoviPrep during the morning. Klean-Prep instructions Morning appointments the day before: Start a clear fluid diet after lunch. Do not eat anything solid after 1pm. At 3pm make up the first litre (1000mls) of Klean-Prep and drink over 1 hour. At 4pm make up the second litre (1000mls) of Klean-Prep and drink over 1 hour. Have a rest for 1 hour At 6pm make up the third litre (1000mls) of Klean-Prep and drink over 1 hour. At 7pm make up the fourth litre (1000mls) of Klean -Prep and drink over 1 hour. *The 4 litres of Klean-Prep is not part of your daily fluid intake. You should drink clear fluids to make sure you do not become dehydrated. Afternoon appointments the day before: Start a clear fluid diet after lunch. Do not eat anything solid after 1pm At 6pm make up the first litre (1000mls) of Klean-Prep and drink over 1 hour. At 7pm make up the second litre (1000mls) of Klean-Prep and drink over 1 hour. The 4 litres of Klean-Prep is not part of your daily fluid intake. You should drink clear fluids to make sure you do not become dehydrated. The day of your examination: At 8am make up the third litre (1000mls) of Klean-Prep and drink over 1 hour. Page 7 of 14

8 At 9am make up the fourth litre (1000mls) of Klean-Prep and drink over 1 hour. Remember do not eat anything on the day of your examination. You can drink clear fluids up to 2 hours before your test. Klean-Prep is vanilla flavoured but lime cordial or orange squash maybe added to vary the flavour. Expect frequent loose or liquid bowel movements then loose motions to start within two hours, which will eventually become clear. You will experience some urgency to go to the bathroom several times therefore stay near a toilet at this time. You may suffer nausea, colic, anal pain or headache during the day. If you suffer severe persistent abdominal pain or feel faint you should contact your GP. Example of a clear fluid diet during bowel preparation Water (it is advisable to drink plenty of water, at least eight glasses per day) Black tea/coffee Lemonade/Coke Lucozade Strained Soup consommé, chicken noodle, vegetable, broth (strain to remove noodles, all solid food and vegetables out) Oxo/Bovril Jelly (only orange, lime or lemon Avoid fluids with artificial colours or sweeteners especially red or blackcurrant juices and tomato soup. Continue to take lots of clear fluid (water, clear squash or pop) until your bowel movements have ceased, drinking as much as you need to satisfy your thirst. It is advisable to drink at least one glass of water every hour during the preparation period. If you have a morning appointment, only drink water after 12 midnight. You may drink water up until two hours before your appointment. You may eat and drink normally after the procedure. What happens on the day of your appointment? Continue to take clear fluids only, to satisfy your thirst until two hours before your appointment time. Take any prescribed medication with a little water at the usual time (except diabetic medications). Bring any insulin and/or diabetes tablets with you. Please complete the enclosed health questionnaire. Please sign the consent form in the middle of this booklet before you arrive, unless you need further information or wish to discuss any issues before you sign it. Page 8 of 14

9 Bring your appointment letter, this booklet (with a list of your medications) and the health questionnaire with you. Do not wear nail varnish or false nails, as this will interfere with the monitor we use. Do not bring valuables or large quantities of money into hospital, as we cannot accept responsibility for them. What happens when you arrive at the Unit? On arrival please report to the reception desk. You will be shown to an admission room where a nurse will check your details and confirm transport and aftercare arrangements with you. A nurse will discuss the procedure with you in detail. If you have any questions please ask. If you are anxious please let us know. The nurse will confirm that you have understood the information you have been sent, have signed your consent form and that you agree to proceed with the procedure. You will be asked to undress and put on a hospital gown. Please bring your own dressing gown and slippers. If you are having sedation a fine needle, a cannula (like a drip) will be placed in a vein in your hand or arm so that a sedative injection can be given when you are in the endoscopy room. You may keep any spectacles on or dentures in until immediately before the procedure. After you have spoken to the endoscopist these will be removed and kept in your trolley. Sedation How will this affect me? Sedation is not a general anaesthetic You will be awake and aware of the procedure Sedation may make you forgetful; you may not remember details of the test. The effects of sedation last in your system for 24 hours. You must have a responsible adult collect you from the department to take you home and it is advisable to have someone stay with you for at least 12 hours following the procedure. Your procedure may not be performed if you have not made these arrangements. What happens during the procedure? You will be taken to the procedure room where you will meet the endoscopist and other staff who will remain with you during the procedure. You will be told if students are present, and if you prefer, you can ask them to leave. You will be asked to lie on your left side. The endoscopist will give your sedation into the cannula in your hand or arm. This will make you sleepy and relaxed but not unconscious. The endoscopist will examine your back passage gently with a gloved finger. The colonoscope will then be passed into the back passage. The instrument is then passed gradually around the rest of the colon. Page 9 of 14

10 We may assist you to change position to aid progress of the scope. Small samples of tissues (biopsies) may need to be taken using forceps passed down the colonoscope. Polyps (small mushroom shaped protuberances of tissues) may be removed (see polypectomy under additional procedures ). Other procedures may be done if necessary (see under Additional Procedures ). Once the procedure is complete, the endoscopist will gradually withdraw the instrument, inspecting the bowel wall and sucking out as much air as possible. If several polyps have to be removed, the scope may need to be passed several times. During the procedure you may be aware of bloating and a sensation to move your bowels or pass wind. Do not feel inhibited from doing either: no stool is present, and this feeling is simply due to the presence of the scope. You may feel a pushing sensation inside as the endoscopist presses round a corner. You may also feel the nurse pressing on your abdomen to guide the scope round the corner. The nurse will be monitoring you throughout the procedures. If biopsies are taken or polyps removed, this does not cause any pain. Sometimes despite bowel preparation there is too much faeces to complete the test. We will advise you of further tests or recommendations. There are certain medical conditions that may make this procedure more uncomfortable. These are a previous hysterectomy, major gynaecological surgery or severe Irritable Bowel Disease. You are entitled to withdraw consent at any time, including during a procedure. Please inform the nurse who is looking after you if you wish the procedure to stop. What happens after the procedure? When the procedure is completed you will be taken to the recovery room on the trolley. Your breathing, pulse and blood pressure will be recorded until you are fully recovered from the initial effects of the sedation, usually after one hour. You will be offered some refreshment and your cannula will be removed. You may feel bloated for several hours, and may pass much wind or a little blood. The endoscopy staff will explain the results to you and tell you if any biopsies have been taken or if any further tests are necessary. We may also recommend treatment to be given by your GP and further measures with which you can help yourself. Results will be communicated to the clinician who organised the procedure. You may leave the hospital when your relative or friend is there to collect you. Remember to restart your iron tablets. Page 10 of 14

11 What are the risks/complications of colonoscopy? Colonoscopy is classified as an invasive investigation and because of that it has the possibility of associated complications. These occur extremely infrequently; we would wish to draw your attention to them and so with this information you can make your decision. The doctor who has requested the test will have considered this. The risks must be compared to the benefit of having the procedure carried out. The risks can be associated with the procedure itself and with administration of the sedation. Risks of the colonoscopy examination The main risks are of mechanical damage. Perforation (risk approximately 1 for every 2,000 examinations) or tear of the lining of the bowel. An operation is nearly always required to repair the hole. The risk of perforation is higher with polyp removal (1 in 1,000). Bleeding may occur at the site of polyp removal (risk approximately 1 for every examinations where this is performed). In the majority of cases, this is controlled at the time of endoscopy; however, rarely this may be severe and require further treatment in hospital. Risks of Sedation Sedation can occasionally cause problems with breathing, heart rate and blood pressure. If any of these problems do occur, they are normally short lived. Careful monitoring by a fully trained endoscopy nurse ensures that any potential problems can be identified and treated rapidly. Older patients and those who have significant health problems, for example, people with significant breathing difficulties due to a bad chest may be assessed by a doctor before being treated. Is there any alternative to colonoscopy? X-ray tests such as barium enema or CT colonography are available but these do not allow samples to be taken or polyps removed and involve a significant amount of radiation. Additional Procedures The need for a polypectomy is normally anticipated before the colonoscopy and the benefits and risks discussed with you then. On rare occasions the need for this procedure may arise during the colonoscopy. If this happens the endoscopist will not be able to discuss the situation with you but a decision will be made in your best interests. These include: 1. Polypectomy When polyps are detected, they can often be removed painlessly by using a wire snare (passed down the colonoscope). This is manoeuvred around the base of the polyp, tightened and the polyp is separated from the bowel by passing a small electric current down the wire (to minimise bleeding). 2. Dilatation (stretching) of any narrowing in the colon. This can be done using a balloon passed through the colonoscope. 3. Stent insertion A sleeve lining (stent) can be placed in your colon to achieve permanent dilatation where the narrowing seems likely to recur soon. Page 11 of 14

12 4. Abnormal blood vessels at any site can be treated with a heating probe to prevent them from bleeding. Research Ninewells Hospital Endoscopy Department is involved in clinical research for the diagnosis and treatment of various gastroenterological conditions. Our research nurse may speak with you during your appointment. Confidentiality Data on certain colonoscopies is collected as part of local or national audit, quality assurance or research programmes. All such data is anonymous before collection, so that patients cannot be identified by anyone other than staff involved in their care. Please let the Unit staff know if you do not wish data from your examination to be included. Discharge advice As you have had sedation: You may get some bruising at the site of the cannula. You may feel slightly woozy and forgetful for the rest of the day. You must have a responsible adult collect you from the department to take you home and it is advisable to have someone stay with you for at least 12 hours following the procedure. For 24 hours following sedation, you must not: drive operate machinery drink alcohol return to work breast feed be responsible for looking after young children sign any legally binding documents You must not use electrical equipment or kitchen appliances such as cookers or kettles for 12 hours. You must not take sleeping tablets on the night after the procedure. Bloating and colic are common for about 12 hours after the colonoscopy. It is rare to have complications following colonoscopy. If you experience: Severe abdominal pain Pass large amounts of blood Have a high temperature Experience vomiting Page 12 of 14

13 Swelling or redness of an injection site then you should contact your GP, or NHS 24. We must take special measures with hospital instruments if there is a possibility you have been at risk of CJD or variant CJD disease. We therefore ask all patients undergoing any surgical procedure if they have been told that they are at increased risk of either of these forms of CJD. This helps prevent the spread of CJD to the wider public. A positive answer will not stop your procedure taking place, but enables us to plan the procedure to minimise any risk of transmission to other patients. You were referred for your test by your: GP Consultant Bowel Screening Programme You will receive the results of your test by letter from the: Colorectal Pathway Consultant Colorectal Nurse Specialist The results of your biopsy will be sent to the person who requested your test You have been discharged from the service You require an outpatient appointment This will be at the Gastroenterology Clinic. This will be on... An outpatient appointment will be sent to you If you were referred through the Bowel Screening Programme, you will go back into the programme and receive another test in two years. Completed by nurse. Comments We would welcome any comments on this information leaflet. Page 13 of 14

14 Remember to bring this booklet! If you have any questions or concerns, call the Endoscopy Unit where you are to have your procedure, between 8.30am and 5pm. Ninewells Hospital: Perth Royal Infirmary: Stracathro Hospital: NHS 24: 111 Checklist Please tick I have read this booklet I have completed the health questionnaire I have signed the consent form Developed by Endoscopy staff and has been reviewed by other staff and patients Revised: 02/2017 Review: 02/2019 LN0033 Page 14 of 14

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