Upper Endoscopy 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.​
Why is upper endoscopy performed?
Upper endoscopy is performed to investigate various causes such as abdominal pain, indigestion, nausea, vomiting, difficulty swallowing, celiac disease, anemia and the cause of bleeding.
​
What is upper endoscopy and how is it performed?
Upper endoscopy is performed with an endoscope, which is a long, thin, flexible tube with a video camera on its end. The endoscope starts with the mouth, first the esophagus, then the stomach, and finally the duodenum. During this time, if inflammation, ulcers, tumors, etc. are detected, a biopsy can be taken. Endoscopy is used not only for diagnosis but also for treatment. In this respect, performing an endoscopy yields much more successful results than taking an X-ray. Stopping a bleeding, removing polyps (mostly benign growths), and opening a stenosis along the gastrointestinal tract are among the procedures that can be performed with endoscopy. The patient usually does not feel much discomfort during this time.
​
How to prepare for upper endoscopy?
It is essential that your stomach is empty. On the day you come for the procedure, you should act as if you are fasting; eating, drinking and smoking are prohibited. Do not eat anything after 8 pm the night before the procedure (you can drink water until 12 am). In some cases, your doctor may give you additional advice. Inform your doctor about the medications you are taking when you make your appointment; it may be necessary to stop some of them. If you are diabetic, state this. If you are allergic to medications or any substances, or if you have medical conditions such as heart or lung disease, be sure to tell your doctor.
​
How is upper endoscopy performed?
In some centers, patients are given a light sedation (tranquilizer) before the procedure. This should not be confused with general anesthesia (narcosis). Sedation provides a light sleep state. However, in many centers, the procedure is performed without sedation, only with a local anesthetic spray sprayed into the throat. This spray has a bitter taste and has a local anesthetic (numbing) effect, thus reducing the gag reflex. Then, a mouthpiece that you can hold with your front teeth is placed in your mouth and you are asked to lie on your left side. The endoscope passes through this mouthpiece and the procedure begins. The endoscope is 1 cm thick. The trachea and esophagus are side by side in the pharynx. Only the esophagus is entered with the endoscope. Since the trachea is completely open throughout the procedure, there is absolutely no risk of choking or suffocation. The 10 cm lighted end of the endoscope is flexible and mobile, and there is a video camera here. In this way, the doctor will be able to see and evaluate the area he is examining one-on-one. During endoscopy, air is injected into the stomach and intestines to allow a better view of the lumen. If the patient is awake and undergoing endoscopy, this will cause them to feel bloated. If possible, avoid belching to expel air during this time, because the lumen is opened with air, allowing the inner tissue of the stomach and intestines to be seen better. The entire procedure takes approximately 15-20 minutes.
​
What happens after an endoscopy?
Patients who are sedated lie down and rest in the observation room for a while after the procedure. The patient who is fully awake goes to the doctor's office with an attendant. Since the effect of the drug sprayed into your throat lasts at least 1 hour, you should not eat or drink anything during this time (swallowing function may be impaired, so it may leak into your throat). You may feel a slight pain in your throat and a bloated abdomen after the procedure. This is due to the local anesthetic sprayed into your throat and the air given into the lumen, do not worry, it is temporary. Unless your doctor tells you otherwise, you can eat and drink 1 hour after the procedure. It is recommended that patients who are sedated do not drive, do not ride public transportation alone, do not use machines that require attention, do not drink alcohol and avoid signing legal documents during that day. These patients must have a relative with them. You will return to your normal life completely the next day. Your procedure report will be sent to you later. If a biopsy was taken, the result will usually be available within 2 weeks. At the end of this period, you can call the office to find out if the result has been received.
​
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 possibility of complications varies depending on the type of procedure, the endoscopic intervention to be performed, and the general health of the patient. If a biopsy has been taken or any intervention has been performed, there may be slight bleeding. In very rare cases, the stomach 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. If any of the following occur, consult your doctor:
​
• Fire
• Difficulty swallowing
• Increasing throat, chest or abdominal pain
• Other symptoms that cause you concern
Key Points
• Upper endoscopy is a procedure performed to see the inside of the esophagus, stomach and duodenum.
• It is performed on an empty stomach. Therefore, do not eat, drink water or smoke before the procedure.
• During the procedure, the doctor will take biopsies of any abnormal looking tissues and polyps.
• After the procedure, avoid doing work that requires attention and do not drive for the rest of the day.
​
Who can I contact if I have questions?
If you have any questions, you can call the practice during business hours.
Attention! Do not forget to hand over your money, wallet and jewelry to a relative before the transaction.
​
Our institution accepts no liability for any injury, loss or damage arising from the use of or reliance on the information contained 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 patient/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.