Mdspecialists.ca

1 Westmount Square, Suite C200, Westmount (QC) H3Z 2P9, Tel. (514) 904-0666 COLO-RECTAL / GASTRO- INTESTINAL DIAGNOSTIC AND
TREATMENT PROGRAM
COLONOSCOPY/GASTROSCOPY - INFORMATION, PREPARATION & CONSENT
THESE INSTRUCTIONS WILL HELP YOU PREPARE FOR YOUR EXAMINATION
WE ASK THAT YOU READ THEM CAREFULLY….
• If you have ever had complications or serious side effects following any previous
colonoscopy or gastroscopoy exam, please call to discuss this with our nurse
prior to your appointment.
inform the nurse before the procedures of any health problems or physical
disabilities you may have, eg: hearing loss or decreased mobility.
• If you are over 70 years of age, diabetic or suffer from hypotension (low blood pressure),
please make sure you were given a morning appointment.
• Please bring with you your Referral from your Physician together with any Medical Reports
(such as blood test results or ultrasound report) relevant to your present condition. • Bring with you a list of your Current Medications and also of your Allergies (to food
and medication). These lists will added to your file.
30 minutes before the time of your appointment so that you may sign
the consent form and prepare for the examination. Please let us know in advance
(72 hrs preferred) if you have to cancel or change your appointment.
• You will not be able to drive for 8 hours after the exam – We suggest you come
to your appointment accompanied by a friend or relative. • You will have 3 hours free underground parking. Please ask for your coupon at the front reception
(enter from St. Catherine Street between Wood and Greene).
• Payment may be made by VISA, Master Card, Debit Card or Cash.
We do not accept cheques.

1 Westmount Square, Suite C200, Westmount (Québec) H3Z 2P9 - Tel. 514)-904-0666 GASTROSCOPY - INFORMATION, PREPARATION AND CONSENT

WHAT IS A GASTROSCOPY?
A GASTROSCOPY is an examination in which a flexible tube (endoscope) is passed through the mouth and
back of the throat into the upper digestive tract. It allows the physician to inspect the lining of the oesophagus,
stomach and duodenum (the first portion of the small intestine). It is used to investigate symptoms such as
difficulty in swallowing, heartburn, abdominal pain, nausea and vomiting. Gastroscopy can be also used to
control bleeding and cancer screening. In case of suspicious area or abnormalities a small piece of tissue (a
biopsy) can be taken for examination in the laboratory. Biopsies are usually taken when ulcers or inflammation
is present and they do not necessarily mean that they are cancerous. Polyps can be also removed. The
gastroscopy is performed as an outpatient exam and usually lasts 10 to 15 minutes. Your throat may be sore
for a few hours and you may feel bloated for a few minutes after your exam, but normally you will be able to
resume your regular diet after 30 min.
The feeling of the tube at the back of your throat may cause discomfort, however the tube will not affect your
breathing. You will be offered intravenous sedation to minimize any discomfort, which will also help you relax
and prevent “gagging”. A local anesthetic may be sprayed onto the back of your throat to reduce the
uncomfortable feeling. You will be monitored in the recovery room of the clinic until the sedation wears off
(approximately 30-45 minutes). Please note that the medication(s) used to sedate you may impair your reflexes
and judgment for the rest of the day. It is therefore strongly recommended that you be accompanied home.
Do not drive or operate any machinery for a period of 8 hours after the exam even if you feel capable of
doing so.
The medication administered may be excreted in breast milk and may also be transferred into the placenta.
Nursing mothers should inquire well in advance of their appointment with the nurse or the physician performing
the exam for more information and precautions to be taken.
Gastroscopy does not stimulate contraction of the uterus and can be performed during pregnancy, without an
administration of sedatives. The consent of the specialist performing the gastroscopy is required prior to the exam.

POSSIBLE COMPLICATIONS: Gastroscopy (with/without biopsy or polypectomy) is associated with a very low
risk of complications when performed by specialized physicians. A perforation - a tear through the wall of the
oesophagus or stomach, which may cause leakage of the digestive fluids - can occur. In this rare case, the
complication may be managed simply by aspirating the fluids until the opening seals. Antibiotic treatments or
surgery may be required. Bleeding may occur after a biopsy or removal of a polyp. It is usually minor and
stops on its own or can be controlled by cauterization. It is extremely rare that a transfusion is needed or
surgery has to be performed to stop the bleeding. Adverse or allergic reactions to the medications are
possible and can be controlled with specific medications. Localized irritation of the vein may occur at the site
of medication injection. A tender lump develops which may remain for several weeks to months but goes away
eventually.
NOTE: The preparation to clean your stomach (gastroscopy) is extremely important to reduce the risk
of aspiration, therefore NO FOOD, NO LIQUIDS 6 hours before your procedures.
1 Westmount Square, Suite C200, Westmount (Québec) H3Z 2P9 - Tel. 514)-904-0666 COLONOSCOPY - INFORMATION, PREPARATION AND CONSENT

WHAT IS A COLONOSCOPY?
A COLONOSCOPY is an examination in which a flexible tube (endoscope) is used to inspect the rectum and the large
bowel after you have followed a “preparation” to clear your colon. In case of abnormalities biopsies can be taken and
polyps can be removed. Many cancers start as a benign polyp and therefore removal of these polyps (polypectomy) is an
important way of preventing rectal and colon cancer. The colonoscopy is performed as an outpatient exam and usually
takes 15 to 30 minutes. You may feel bloated for a few minutes or hours after your exam. Normally you will be able to
resume your regular diet after 30 min.
There may be some discomfort associated with the examination. You will be offered intravenous sedation to minimize
any discomfort. You will be monitored in the recovery room of the clinic until the sedation wears off (approximately 30-
45 minutes). Please note that the medication(s) used to sedate you may impair your reflexes and judgment for the rest of
the day. It is therefore strongly recommended that you be accompanied home. Do not drive or operate any
machinery for a period of 8 hours after the exam even if you feel capable of doing so.
The medication administered may be excreted in breast milk and may also be transferred into the placenta. Nursing
mothers should inquire well in advance of their appointment with the nurse or the physician performing the exam for more
information and precautions to be taken.
Colonoscopy can also stimulate contraction of the uterus. Pregnant patients should not have this exam without the
prior consent of the specialist performing the colonoscopy.

POSSIBLE COMPLICATIONS: Colonoscopy and polypectomy are associated with a very low risk of complications when
performed by specialized physicians. A perforation (a tear in the wall of your intestine) may occur (in less than 0.1% of
cases). In these very rare cases, antibiotic treatments or surgery may be required. Bleeding may occur after a biopsy
and/or the removal of a polyp. It is usually minor and stops on its own or can be controlled by cauterization. It is
extremely rare that a transfusion is needed or surgery has to be performed to stop the bleeding. Adverse or allergic
reactions to the medications are possible and can be controlled with specific medications. Localized irritation of the vein
may occur at the site of medication injection. A tender lump develops which may remain for several weeks to months but
it will go away eventually.
HOW TO PREPARE FOR YOUR COLONOSCOPY:

You will need to follow specific instructions if you are taking certain medications or if you have certain
conditions.
Please check the instructions on the following page carefully to see if they apply to you.
Should you need additional information or clarification after reading these instructions, please inquire with our nurse well in advance of your appointment. 1 Westmount Square, Suite C200, Westmount (Québec) H3Z 2P9 - Tel. 514)-904-0666 TO PREVENT COMPLICATIONS YOU MAY HAVE TO STOP TAKING (OR TAKE)
CERTAIN MEDICATIONS BEFORE COMING FOR YOUR APPOINTMENT
Please Stop Taking …
(Please check with your referring physician before you stop taking any medication)
Medication
Examples
For how long before your colonoscopy appointment
Blood Thinners --
Blood Thinners –
ALL Anti-
Except Advil
inflammatory
Medication
(Advil can be taken)
(NSAIDs)
Multivitamin pills which contain iron, or
patches do not have to be stopped
.
ALL Medication to
For appointments before noon:
regulate
NO EXCEPTIONS
Blood Pressure
For appointments after noon:
Over-the-Counter
These do not have to be stopped
Medication
The day before your colonoscopy: Take only half your normal dose.
(injected)
The day of your colonoscopy: Do not take insulin in the morning
Oral medication
From the time you begin the
for Diabetes
Clear Liquid Diet
Please Let Us Know when You Make Your Appointment …
IMPORTANT !
If for any reason you cannot follow the instructions above or if you need further information please give us a call and speak with our nurse at (514) 904-0666 ext.: 2008 at least 48hrs before your
appointment (leave a message and the nurse will call you back). 1 Westmount Square, Suite C200, Westmount (Québec) H3Z 2P9 - Tel. 514)-904-0666 PREPARATION
The preparation to clear your colon with a laxative is extremely important so that the mucous membrane is clearly visible
during the colonoscopy. Please use ONE of the following laxatives to clear your colon. If you have kidney disease or are
suffering from constipation you must use OPTION 1. You do not need a prescription for any of the laxatives.
BOTH PREPARATIONS REQUIRE YOU TO TAKE LOTS OF CLEAR LIQUIDS. These include: Soup Broth,
Gatorade, Clear Fruit Juices (Apple, White Grape, White Cranberry, Orange and Grapefruit (pulp-free), Kool-aid, black
Coffee and Tea, Soft Drinks and Kool Aid. You may also eat Ice Popsicles, clear Jell-O without fruit and Hard Candies.
DO NOT TAKE MILK OR MILK PRODUCTS
DO NOT TAKE DRINKS, POPSICLES OR JELL-O WHICH ARE COLOURED RED OR PURPLE
NOTE: YOU WILL HAVE DIARRHEA AND WATERY BOWEL MOVEMENTS AFTER YOU TAKE EITHER
LAXATIVE PREPARATION
OPTION 1 - GOLYTELY or PEGLYTE + 2 DULCOLAX TABLETS
(Use this option if you have kidney disease or are suffering from constipation)
The instructions are the same whether your appointment is before or after 2.00 PM • BUY 1 Container of GOLYTELY or PEGLYTE and a Package of DULCOLAX Tablets

• MAKE UP the solution as directed on the container
THE DAY BEFORE YOUR APPOINTMENT:
• For the whole day DRINK ONLY CLEAR LIQUIDS
• Starting between 4.00 PM and 6.00 PM - Drink 1 glass (250 ml/ 8 oz) of the GOLYTELY every 10 minutes
until it is finished. If you become too bloated, wait until you have a bowel movement and then continue to drink until the bottle is finished. • AT 9.00 PM TAKE 2 DULCOLAX tablets.
THE DAY OF YOUR APPOINTMENT:
• KEEP DRINKING CLEAR LIQUIDS UNTIL 6 HOURS BEFORE YOUR APPOINTMENT

OPTION 2 - PICO-SALAX – You may use this option only if you do not have kidney disease, suffer
from constipation or take anti-depressants on regular basis
• BUY 1 Carton of PICO-SALAX (contains 2 sachets) + 2 Ducolax tablets
Do not follow the instructions on the package. Prepare as follows:
• Empty the contents of one sachet into a cup
• Add 150 ml. (approx. 5 oz) cold water
• Stir for 2 to 3 minutes
• Prepare the second sachet in the same way
After you drink each Pico-Salax sachet - you must then also drink at minimum three 10-oz glasses of
clear liquids every hour for the next four hours (if you do not drink enough water the laxative may not
be effective).
THE DAY BEFORE YOUR COLONOSCOPY:
• You may eat a LIGHT BREAKFAST (an egg and white toast – NO cereal).

• AFTER BREAKFAST AND FOR THE REST OF THE DAY you should drink only CLEAR LIQUIDS
(SEVERAL LITRES)

• AT 3.00 PM drink the first sachet of prepared Pico-Salax and then drink clear liquids as outlined above.
• AT 8.00 PM drink the second sachet of prepared Pico-Salax and then drink clear liquids as outlined above.
• At 11 PM take your 2 Ducolax tablets
1 Westmount Square, Suite C200, Westmount (Québec) H3Z 2P9 - Tel. 514)-904-0666

THE DAY OF YOUR PROCEDURES:

• Keep drinking clear liquids until 6 HOURS before your appointment
IMPORTANT POINTS TO REVIEW:

• I will stop taking all blood thinners and all other medications as specified on this form.
• I will properly follow one of the two preparations to clear my colon.
• I will come 1 hour before my appointment to take my antibiotic if I suffer from heart valve disease…
• I will bring a list of all my medications & allergies the day of my colonoscopy appointment.
• I will not drive or operate machinery for 8 hours after my exam was performed under sedation.
• I am aware that the medication administered may be excreted in breast milk. If I am breast-feeding, I will inquire
with the nurse or my own physician well in advance about what precautions to take. • I am aware that this exam cannot be performed during pregnancy, without a specialist’s prior consent.
INFORMED CONSENT

I, _______________________________ hereby agree to allow Dr. to perform a
gastroscopy and colonoscopy on me with or without biopsy or polypectomy.
I understand that the Diagnostic and Treatment Program that I am hereby requesting includes, among other things, the
presence of a registered nurse for monitoring during and after sedation. I specifically request the presence and accept to
pay the related fees. I have been informed that these fees are not reimbursable by the provincial health insurance (Medicare)
or by most private health insurances.
I have read and understood the contents of this form, including the risks and possible complications associated with the
procedures which have been clearly explained to me. I had the opportunity before the procedures to direct all my
questions to the attending nurse and was provided with satisfactory answers.
I consent to undergo these two procedures;
I am not breast-feeding: ___________________________________________________________ (Patient’s signature).
I am not pregnant and do not think I may be pregnant: ________________________________ __ (Patient’s signature).
If you are pregnant, think you may be pregnant or are breast-feeding the doctor’s signature is required:
_______________________________________________________________________________________________ ___(Doctor’s signature). Should there be any question of medical malpractice, I agree to adjudication only within the Province of Quebec, and under the laws of the Province of Quebec. _________________________________________________ _______________________________________________________ ___________________________________________ _________________________________________________ (Date) Please bring this consent form (unsigned) with you on the day of your appointment
Thank You !
1 Westmount Square, Suite C200, Westmount (Québec) H3Z 2P9 - Tel. 514)-904-0666

Source: http://www.mdspecialists.ca/forms/combinedcandgscope.pdf