Colonoscopy Consent Form
Dear Patient, Dear Protector/Guardian please read this form carefully. This form has been created to inform you about the procedure. As a result of the information, you have the right to undergo or refuse the procedure with your free will.
What is a colonoscopy?
Colonoscopy is an examination of the large intestine to diagnose and, in some cases, treat diseases. This procedure is performed with a colonoscope, a long, thin, and flexible tube with a video camera at its end, and is inserted through the anus (rectum) to allow examination of the entire large intestine. In this way, the doctor can take a sample (biopsy) of any abnormalities seen during the procedure, or can treat this abnormal tissue (such as a polyp) by removing it completely.
Why should you have a colonoscopy?
Colonoscopy can detect polyps, inflamed tissue, and malignant tumors such as colorectal cancer. It is also an extremely useful method for diagnosing unexplained changes in bowel habits, abdominal pain, intestinal bleeding, and weight loss. It should be performed especially in people with a family history of colon cancer, and the entire colon should be scanned for this reason. In this way, colon cancer can be prevented before it occurs.
How to prepare for a colonoscopy?
For a colonoscopy to be successful (optimal), the intestines must be completely cleared of feces. Otherwise, some areas of the colon cannot be seen completely and the procedure will be incomplete (suboptimal procedure). For this reason, it is very important to use the diarrheal medication recommended to you very carefully and completely.
Bowel preparation is done as follows:
1. Colonoscopy preparation diet
Preparation begins a few days before the colonoscopy. During this period, avoid foods containing seeds and grains because they can block the suction channel of the device. Fibrous foods are difficult to digest and therefore difficult to remove from the intestines, and should not be taken.
2. Bowel preparation
There are various laxatives that empty the colon by causing diarrhea. Your doctor will recommend the most appropriate one for you based on your medical condition.
3. Drink plenty of fluids
Your doctor will give you specific instructions for preparation.
Before the procedure, you must tell us about all your medical conditions (current and past illnesses) and any medications, vitamins or supplements you are taking. Iron medications are usually stopped one week before the procedure (since the color of the medication impairs endoscopic vision).
How is a colonoscopy performed?
Sedation (Tranquilizer)
In some centers, patients are given a mild sedation (tranquilizer) before the procedure. This should not be confused with general anesthesia (narcosis). Sedation induces a mild state of drowsiness; however, sedation is still not used in many centers in Turkey. Sedated patients may be vaguely aware of what is happening in the procedure room, but will generally remember very little about the procedure. The doctor and medical staff will monitor your breathing, pulse and blood pressure at regular intervals to ensure your comfort during the procedure. A colonoscopy usually takes 20 to 45 minutes.
Examination of the large intestine
The procedure is performed lying on your left side. The doctor enters through the anus and starts to examine the large intestine. A small camera at the end of the colonoscope transmits a video image of the colon to the monitor. In this way, the inner surface of the intestine can be easily examined on the screen. When the colonoscope reaches the point where the small intestine joins the colon, the terminal ileum, the end point of the small intestine, is also included in the examination.
Removal of polyps and biopsy
A polyp is a small growth of tissue in the intestinal wall. Polyps are common in the population and are usually harmless, but a small proportion can develop into cancer. Since removing them prevents cancer, if detected by colonoscopy, the polyp is removed from the large intestine by polypectomy or mucosectomy (endoscopic removal of the polyp). If the polyp is small, it can be removed completely during the biopsy, but if it is large, a biopsy is performed and the patient is postponed to the next session. In the second session, the entire polyp can be removed by polypectomy or mucosectomy. In addition, small tissue samples (biopsies) can be taken from the colon to be examined under a microscope for other diseases of the colon. Patients who are sedated rest in the observation room for a while after the procedure. When the patient is fully awake, he or she goes to the doctor's office accompanied by an escort. When you are fully awake, you can have something to eat and drink. During the endoscopy, air is blown into the stomach and intestine to get a better view of the lumen (inside the intestine). The patient may feel a little bloated. This usually goes away within an hour or two. Rarely you may see a small amount of blood. This is usually due to the biopsy. Patients who have been given sedatives are advised not to drive, take public transport alone, operate machinery that requires attention, drink alcohol and refrain from signing legal documents during the day. These patients should be accompanied by a relative. The next day you will return to your normal life.
Are there any risks or side effects?
The doctor who will perform your procedure is a gastroenterologist and has received special training in endoscopy, so complications related to the procedure are extremely rare. The probability of complications varies depending on the type of procedure, the endoscopic intervention to be performed, and the general health of the patient. If the patient has had a biopsy or any intervention, there may be slight bleeding. There is an approximately 0.1% chance that the intestinal lining may rupture and surgery may be required. In addition, very rarely, allergic reactions to the medications administered may occur. Patients who cannot tolerate endoscopy and therefore cannot complete the procedure are given a new appointment. Laxatives used to empty the bowel can cause headaches or vomiting in some patients. If any of the following symptoms occur within 14 days after the colonoscopy, contact your doctor or a healthcare provider.
● Severe abdominal pain
● Black, tarry stools
● Continuous bleeding from the anus
● Fire
● Other symptoms that should worry you
How accurate is a colonoscopy?
Colonoscopy provides the most accurate examination of the colon. However, no test is perfect and there is always a small risk that an abnormality may not be detected. Small polyps in the colon can be missed by colonoscopy in 2 to 8% of cases. This is much less likely, but still possible, for larger abnormalities such as cancer. For this reason, it is recommended that all patients over the age of 50 or those with a family history of colorectal cancer have a fecal occult blood (FOB) test and/or a medical check-up every 1-2 years.
Key points:
● Colonoscopy is a procedure performed to see the inside of the colon and rectum.
● On the day of your procedure, you must behave as if you were fasting; eating, drinking and smoking are prohibited.
● Before the procedure, use the laxative prescribed to you in full to evacuate all stool from the intestine. Read the instructions carefully.
● During the colonoscopy, the doctor will take biopsies of any abnormal-looking tissues and polyps.
● After the procedure, avoid tasks that require attention and do not drive throughout the day.
Who can I contact if I have questions?
If you have any questions, you can call the office during business hours.
Attention! Do not forget to hand over any money, wallet or jewelry you have with you to a relative before the transaction. Our institution accepts no responsibility for any injury, loss or damage resulting from the use or reliance on the information in this brochure.
Consent statement by the patient, parent or guardian:
My doctor has given me the necessary explanations about my health condition.
I have received detailed information about the planned treatment/intervention, its necessity, the course of the intervention and other treatment options, their risks, the consequences that may arise if I am not treated, the probability of success and side effects of the treatment.
I understood what I should pay attention to before and after the treatment/intervention.
It was explained to me that all documents and samples taken during my diagnosis/treatment/intervention can be used for educational purposes if necessary.
My doctor answered all my questions in the way I could understand.
I have gathered information about the individuals who will perform the treatment/procedure.
I am of sound mind and consider myself competent to make decisions.
I know that I do not have to consent to the treatment/intervention if I do not want to and/or that I can withdraw from the procedure at any stage.
Note: Please write in your handwriting “I have read, understood and accept this consent consisting of 2 pages” and sign it. ....................................................................................................................................... .....................
Name, surname and signature of the protector/parent/guardian/relative (degree of closeness): Name, surname and signature of the physician:
Date/Time :
Name, Surname and Signature of the person providing communication (e.g. interpreter) in case direct communication with the patient cannot be established:
Signature:
Date:
I have conveyed the information in the “Informed Consent Form” to the patient, his/her parents or relatives to the best of my ability.