Upper gastrointestinal endoscopic ultrasound

Upper gastrointestinal endoscopic ultrasound A guide to the test Information for patients Endoscopy

Introduction You have been advised to have an upper gastrointestinal (GI) endoscopic ultrasound, which is sometimes referred to as EUS. We have written this booklet to help answer some of the concerns you may have about the test. It may not answer all of your questions. If you have any worries please don't hesitate to ask. The endoscopy booking number is: 0114 271 2990 You may get an answer machine, if so please leave a message and contact number and someone will get back to you. The aims of this booklet are: To explain what happens on the day of your test. To answer some of the questions you may have about the test. page 2 of 16

What is an EUS? This is a test that combines ultrasound and upper GI endoscopy (gastroscopy) and will allow the endoscopist to look at the lining of your gut, including your oesophagus (gullet), stomach, and the first part of your small bowel (duodenum). It also allows the structures beneath the lining to be examined and small samples taken (a biopsy) using the ultrasound. The test is done by passing a long flexible tube through your mouth, into your stomach and the first part of your small bowel. The flexible tube, called the endoscope, has a mini video camera built into its tip and a small ultrasound probe on the end. Pictures and images are then seen on a TV monitor. A video recording or photographs can be taken for record or documentary purposes. Oesophagus Stomach Duodenum page 3 of 16

Why do I need an endoscopic ultrasound? You have probably already had a test which has detected an abnormality, for example a swelling or narrowing in the gut wall, pancreas or gall bladder. Endoscopic ultrasound allows these to be looked at in more detail. The test is useful to determine the size, or even the cause of your problem. Endoscopic ultrasound is the best way of looking at, and taking samples from, the lining of the oesophagus, stomach and surrounding structures or layers. Can there be complications or risks? Most of these procedures are safe and uncomplicated. However, as with any procedure, there is a small chance of side effects or complications: A reaction to the sedative: the sedative can affect your breathing, making it more slow and shallow. Perforation: which is a tear in the wall of the upper GI tract, this is rare. This would require a short stay in hospital and may require an operation to repair the hole. The risk is less than 1 in 1000. Bleeding: if a small sample of tissue is taken there is a small chance of bleeding. Infection: there is a small risk of infection if a tissue sample is taken, therefore antibiotics may be given. Pancreatitis: If a biopsy of the pancreas is performed (you will have been told this before the referral by your doctor) there is a 1 in 100 risk of inflammation in the pancreas which causes pain following the procedure. This may require an overnight stay to ensure you would be comfortable. You may suffer from a sore throat or feel some wind in your stomach. These will settle in a few days. There is a small risk of damage to crowned teeth or dental bridge work. page 4 of 16

You should also be aware that this examination is not perfect and even with a skilled Endoscopist some abnormalities may be missed. If you are worried about any of these, please talk to one of the doctors or nurses about it during your visit How is the test done? The test is done using an anaesthetic spray to numb your throat and an injection to make you sleepy. On rare occasions the sedations can be avoided but we will recommend that you have sedation to make you sleepy since the scanning procedure is better done when patients are relaxed. If you agree to have sedation, a relative or friend must be free to take you home and stay with you overnight. It is not safe to drive or operate machinery for 24 hours after sedation has been given. Preparation for the test Your stomach should be empty to allow a clear view. If your appointment is in the morning: please do not eat or drink after midnight in preparation for the test. If your appointment is in the afternoon: please do not eat or drink after a light early breakfast (for example toast and drink only between 7.00am - 8.00am) on the day of the test. page 5 of 16

Medication If you are taking anti-blood clotting medicines such as Warfarin or Clopidogrel (Plavix), rivaroxaban, dabigatran or apixaban please contact the Endoscopy Suite as soon as possible as these should be stopped up to 7 days before your procedure, especially if you are having a biopsy. If you take essential medication, for example for epilepsy or a heart condition, you may take these with a little water. Please try to take them as early as possible before your test as some tablets leave a residue in the stomach, which may affect the quality of the results. Do bring your other tablets or medicines with you so that you can take them after you have had your procedure. If you are diabetic, please refer to the 'Managing your diabetes' booklet which you received with your appointment letter. The number to call is: 0114 271 2990 You may get an answer machine. If so, please leave a message and contact number and someone will get back to you. Before your appointment Before you come to the Endoscopy Suite you should: Ensure you have completed your pre-assessment questionnaire and returned it to the Endoscopy Suite. If you are suffering from a sore throat, cold or chest infection you should contact the Endoscopy Suite as it may be necessary to postpone your test because of the risks from sedation. Bring with you any letters or cards you have received from the hospital. page 6 of 16

Bring any tablets you are currently taking. It is especially important to remember any asthma inhalers, angina sprays or diabetic medication. Follow all instructions included with this booklet. You should not bring valuables or large amounts of money into hospital; we cannot accept responsibility for them. Do not drive yourself to or from hospital. Make sure someone is able to bring and collect you as you must have a responsible adult to accompany you home. How long will I be in hospital? Please allow for a half-day stay at the hospital. We ask all of the appointments to arrive half an hour early to prepare for the procedure. When you arrive at the Royal Hallamshire Hospital On arrival at the hospital please go into the main building on B road, Royal Hallamshire Hospital. The procedure takes place either: in the Endoscopy Unit located in the Day Case Centre on B road, or on P Floor in the Clinical Investigation Unit, which is accessed by the lift from the main entrance. Please check your appointment letter for which unit it will be in. A nurse will come to do your pre-assessment. This involves checking your pulse and blood pressure, whether you have any allergies, and confirming your discharge arrangements. Please feel free to ask questions or voice any worries you may have regarding your test. The nurse will explain the sedation (injection) and local anaesthetic (throat spray). Both are available for you to have for your procedure. The endoscopist will discuss this with you also. page 7 of 16

The procedure will last 20-45 minutes. This is much longer than a normal gastroscopy test that looks into the stomach. Although a standard gastroscopy can be tolerated with just throat spray, the duration of the procedure and the size of the endoscope means that it can be distressing to undergo an EUS test with just throat spray. We therefore perform the procedure with throat spray and sedation to enable you to undergo the procedure with minimal distress, unless there are special circumstances which you are welcome to discuss with the team on arrival. Throat spray This is a local anaesthetic spray to numb your throat. It has a slightly bitter banana taste. You may have the feeling of a 'lump' in your throat or a gritty tongue; this is normal following throat spray and the sensation will wear off over about an hour. Sedation This is a sedative injection which may make you sleepy. It is not like a general anaesthetic so you may still be aware of having the procedure. It does however sometimes have a short term 'amnesic effect' which means you may not remember having the procedure. You will be less anxious You may be sleepy You may not remember the test at all You will need to be monitored carefully You will take longer to recover You will not be able to drive home You will need to have an adult with you to take you home. We advise you do not take any sleeping tablets on the day of your procedure if you have had sedation. page 8 of 16

If you have sedation you will need to have an adult with you to take you home and you must have a relative or friend with you who can also stay with you overnight. A small plastic needle will be inserted into a vein in your hand or arm so that the endoscopist can give you some sedative medication. You will be called through for examination and the endoscopist will discuss the procedure with you. Again if you have any questions or are unsure, please ask. It is necessary to remove any false teeth if you wear them. They will be kept safe until after the test. Consent We must seek your consent for any procedure or treatment beforehand. Staff will explain the risks, benefits and alternatives where relevant before they ask for your consent. If you are unsure about any aspect of the procedure or treatment proposed, please do not hesitate to ask for more information. What should I know before deciding? The endoscopist or health professional will ensure you know enough information about the procedure to enable you to decide about your treatment. They will write this information on the consent form as well as discussing choices of treatment with you. We encourage you to ask questions and inform us of any concerns that you may have. It may be helpful for you to write these down as a reminder (see back page). What are the key things to remember? It's your decision! It is up to you to choose whether or not to consent to what is being proposed. Ask as many questions as you like and please express any concerns about medication, allergies or past medical history. page 9 of 16

Will any medical or nursing students be involved in my care? Sheffield Teaching Hospitals Trust is a teaching organisation and has a responsibility to ensure that students (both medical and nursing) receive a high standard of training. The Endoscopy Unit is a regional Training Centre. Occasionally there may be students observing procedures in the department or the doctor may be a trainee under the supervision of an experienced Endoscopist. In either case you will be told of any student involvement beforehand. Please remember that you do not have to let students be part of your care so please tell us if you do not want them involved. The Trust also employs Nurse Practitioners who, after training, undertake endoscopic examinations. In all these cases you will be informed beforehand and it is your right to refuse anything you are not comfortable with. What happens during the test? During the test, there will be two nurses to assist with the procedure. You will be seated or laid on a bed and local anaesthetic will be sprayed onto the back of your throat. This will numb your throat and make the test easier. A sedative injection will be given and oxygen will be placed through a tube under the nose. A small peg will be placed on your finger to measure your heart rate and oxygen level. A fabric sleeve will be placed around your upper arm to monitor your blood pressure. It is necessary that you lie on your left side for the test. To keep your mouth open a plastic mouth guard will be placed between your teeth. When the Endoscopist passes the gastroscope into your stomach it is uncomfortable but will not interfere with your breathing at any time. page 10 of 16

The test will last anywhere between 20 and 45 minutes. If you get a lot of saliva in your mouth the nurse will clear it using suction. When the examination is finished, the tube is removed quickly and easily. What happens after the test? If you chose to have the test done with throat spray only, you will be able to go home as soon as you feel ready to leave. Because your throat has been numbed you will be asked not to have anything to eat or drink until you are able to swallow normally. This usually takes about an hour. The back of your throat may feel sore for the rest of the day. It will settle without any treatment. You may also feel a little bloated if some of the air has remained in your stomach. This feeling should pass naturally in time without requiring treatment. If you chose to have throat spray and sedation you will have to rest in the recovery area for approximately one hour. The staff in the recovery area on both units will ensure that your privacy is maintained at all times. You may feel a little bloated with wind pains, these usually settle quickly once you have passed the wind and will not need any treatment. Once you are fully awake the needle used to give you the sedation will be removed. You will then be able to get up, get dressed, and have a drink and something to eat. The effects of the sedation can last for at least 24 hours and even though you will probably feel perfectly recovered, your judgment can remain impaired during this time. page 11 of 16

It is therefore important that you do not: drive a car operate machinery or domestic appliances, as your reaction times may be slowed drink alcohol sign legally binding agreements we also advise that you do not take any sleeping tablets on the day of your procedure if you have had sedation. You must: follow any instructions that your doctor or nurse has given you. What should I do if I feel unwell after arriving home? You may feel a little bloated with wind pains; these usually settle quickly once you have passed the wind and will not need any treatment. However if you have any on-going pains or problems from the procedure you are welcome to call the following numbers for advice: Monday 8.00am to Friday 4.00pm - the Clinical Investigation Unit 0114 271 2218 At the weekend - the Gastroenterology Ward at the Northern General Hospital (Robert Hadfield 4) 0114 226 6554 When can I get back to my normal activities? You should be ready to get back to your normal activities by the next day. page 12 of 16

Getting your results The Endoscopist may be able to tell you the results of your tests straight away. However, if you had sedation you may not remember what has been said. To make sure you have had and understood your results, the recovery nurse will give them to you again when you are fully awake. A copy of the procedure report will be sent to your GP/referring doctor. Further details of the examination and any necessary treatment should be discussed with your GP in 10 to 14 days or at your next outpatient appointment. If you have any problems when you go home, or are feeling worse than you expected, please contact the Endoscopy Department on the telephone numbers given to you. Frequently asked questions and answers 1. If my symptoms have stopped before the Endoscopic Ultrasound, should I still come for the test? Yes. It is important that you still come for the test. Your doctor has organised this test to ensure you have no problems in your oesophagus (gullet), your stomach and your duodenum. Although your symptoms may have gone, it important to have a look to ensure all is clear. 2. Will it hurt? You will not feel any tissue samples that are taken, however, you are likely to feel some discomfort as air is pumped and the tube is passed into your stomach and duodenum so the endoscopist can get the best pictures. Some patients find the air used to inflate the stomach slightly uncomfortable. It should not hurt but some people can find it distressing. Because of this we usually recommend you undergo the procedure with a sedative. page 13 of 16

3. Can I drive home after the procedure if I choose to have sedation? If you have sedation you will not be allowed to drive home and must arrange for someone to accompany you and drive you home. Medication given during the test will prohibit you from driving until 24 hours after your examination. Please do not plan to take public transport home. If you are unable to arrange transportation we can arrange a taxi to take you home, however, you are responsible for the fare. You will need a responsible adult with you for at least 12 hours. 4. Will I get my results on the day? On completion of the endoscopic ultrasound the findings will be discussed with you. We will be able to tell you any visual findings, however any biopsies will need to be sent to the laboratory for testing, and this can take up to 3 weeks. A copy of the procedure report will be sent to your referring doctor and your GP. 5. Can I park at the hospital? Yes. We have a car park, this is indicated on the enclosed map. The rates (at the time of publication) are as follows: 0-2 hours: 2.50 2-4 hours: 3.70 4+ hours: 8.40 Parking is limited, so we recommend using public transport if at all possible. 6. Can I get public transport to the hospital? Yes. You may use public transport. See below for details of how to find out which bus routes serve the Endoscopy Suite you are visiting. Please remember if you have sedation you will not be able to travel home using public transport. page 14 of 16

Traveline: 01709 51515 www.travelsouthyorkshire.com/default.aspx Please use this space to make a note of any questions you may have about your test. Notes... page 15 of 16

Notes... Produced with support from Sheffield Hospitals Charity Working together we can help local patients feel even better To donate visit www.sheffieldhospitalscharity.org.uk Registered Charity No 1169762 Alternative formats can be available on request. Please email: alternativeformats@sth.nhs.uk Sheffield Teaching Hospitals NHS Foundation Trust 2018 Re-use of all or any part of this document is governed by copyright and the Re-use of Public Sector Information Regulations 2005 SI 2005 No.1515. Information on re-use can be obtained from the Information Governance Department, Sheffield Teaching Hospitals. Email infogov@sth.nhs.uk PD4447-PIL1472 v6 Issue Date: June 2017. Review Date: June 2020