COLONOSCOPY INFORMED CONSENT INFORMATION

You and your doctor are considering a procedure called “Colonoscopy”. This is a procedure in which a doctor inserts a specialized instrument into your lower gastrointestinal tract. The colonoscope allows the doctors to see inside the colon, rectum and lower small bowel and to perform procedures.

The removal of polyps and/or biopsy of the colon, rectum or lower small bowel are the most common procedures done during a colonoscopy. These procedures are done to aid in the diagnosis of colorectal disease and to prevent the development of cancer. Your doctor can make no guarantees that this procedure will be successful in making either a diagnosis or a preventing future cancer development.

Significant complications from a colonoscopy are very uncommon (less than 0.3%), but they do occur.

• Bleeding – It is possible for some bleeding of the colon to occur following this procedure. If bleeding should occur, it usually stops by itself. Notify your doctor if you have persistent bleeding, or any amount that alarms you. The reported risk of significant bleeding, in the literature, following colonoscopy is less than 1 in 15,000 procedures. Make sure your doctor knows if you are on medications or have medical conditions that increase your risk of bleeding.
• Perforation – A very rare, but significant complication is perforation. This is an injury to the lining of the colon, which could result in leakage of the digestive products into the body cavity. If this occurs, surgery to repair the injury may be necessary. Statistically, this happens in less than one in every 2,000 patients who have a colonoscopy.

If you experience persistent or worsening abdominal pain in the hours and days following your examination immediately notify your colonoscopy doctor and/or your primary care doctor and/or present to your local emergency room.

Other potential risks include localized irritations of the vein where the medication was injected, a reaction to the sedative used, aspiration of saliva or stomach contents, fever that requires antibiotics, or a complication from a pre-existing medical condition, such as heart or lung disease or diabetes.

Furthermore, there may be alternatives to this procedure available to you, such as the use of other diagnostic tests including Virtual Colonoscopy or barium enema evaluation. However, these alternative methods carry their own risks and complications with varying degrees of success.

I certify that I’ve read, or had read to me, the contents of this form. I understand the risks and alternatives involved with this procedure. I will be given the opportunity to ask questions which I may have, and you have the option to further discuss this consent with the doctor.