Procedure Information

Please read this patient information as soon as possible and well in advance of your appointment. If you do not follow the advice on how to prepare for your procedure it may not be possible to do it and you may have to return on another day.

Please bring this patient information and consent form with you when you attend for your appointment.

Helpline or enquiries (8.30am to 5.00pm Monday to Friday)

Appointments and general enquiries. Our Booking Service covers all sites so please ring any of the numbers below

01205 445072

01476 464366

01522 573849

Procedure related enquiries (8.30am to 6.00pm Monday to Friday)

Boston           01205 446559

Grantham      01476 464085

Lincoln           01522 573016

Louth              01507 631236

For more information please see:  www.ulh.nhs.uk/services/endscopy

BOWEL CANCER SCREENING PROGRAMME PATIENTS: Please ring 01522 597548 for all enquiries

Aim of the patient information

The aim of this patient information is to help you make a choice about having a colonoscopy. It describes how a colonoscopy is carried out and explains the benefits and risks. It will also help you prepare for the procedure.

Introduction

You have been advised to have an investigation known as a colonoscopy.

If you are unable to keep your appointment, please notify the department as soon as possible as your appointment may be used for someone else. The booking team will arrange another date and time for you. Please bring this booklet with you when you attend.

Enclosed with this booklet is a consent form. Your signature is needed for the test to go ahead.

The consent form is an important document. Please read it carefully together with the information in this booklet. Please bring both the consent form and booklet with you to your appointment.

We may contact you a few days before your appointment to discuss the procedure and preparation in more detail. You will also be given the opportunity to ask questions in the department when you attend for your appointment.

In case of any problems please contact the relevant endoscopy unit (telephone numbers are given on page 2 of this booklet).

What is a colonoscopy?

The test involves looking at your large bowel (colon) with a narrow flexible tube called a colonoscope (scope). The scope is inserted through the back passage (bottom) and passed around the bowel. The procedure is performed by, or under the supervision of, a trained doctor or nurse (endoscopist). A light and camera at the end of the scope relay pictures onto a television screen. Carbon dioxide is used to inflate the bowel and help the endoscopist see better.

Samples of tissue (biopsies) may be taken during the test. This is done through the scope. It does not cause any pain, and the samples are kept to be looked at under a microscope in the laboratory. Photographs may also be taken for your medical records and may be used for teaching purposes.

The procedure generally takes about 30 to 40 minutes but may take up to an hour.

What are the benefits of having a colonoscopy?

If you have been troubled by symptoms, the cause may be found and help decide if you need treatment or further tests.

If a polyp is found this can often be removed during the procedure (there is more information about polyps later in this booklet).

Colonoscopy may be done as a follow up inspection if you have had a polyp in the past or other disease of the large bowel.

If a scan or x-ray has suggested there may be something wrong in the large bowel, a colonoscopy allows a closer look at the area.

What are the risks of the procedure?

Complications are rare. These may be linked to the procedure itself or the sedation medicine.

Perforation or tear of the bowel (about 1 for every 1,700 cases). About half of those with a perforation will need surgery to repair it.

Bleeding may happen where a biopsy is taken or a polyp removed (about 1 for every 150 cases). This can happen up to 2 weeks after the procedure. It usually stops on its own but may need cauterisation or injection treatment. In some cases, a blood transfusion may be needed (around 1 person in every 2,400).

There is a small chance that a polyp or cancer may not be seen (about 5 in every 100 cases). This might be because the bowel was not completely empty or, on rare occasions, that the endoscopist missed seeing it.

There is also a small chance (about 10 in every 100 cases) that the endoscopist may not be able to pass the scope along the entire length of the bowel and a different investigation will be needed.

Sedation can sometimes cause problems with breathing, heart rate and blood pressure. If any of these problems do occur, they are usually short lived. Careful monitoring by a specially trained endoscopy nurse means that potential problems are picked up early and dealt with quickly.

In extremely rare cases the procedure can lead to death. However, in a national audit of 20,085 colonoscopies carried out in 2011, no deaths were recorded.

What are the alternatives?

CT colonography (virtual colonoscopy) is another way to look at the large bowel. This is carried out in the x-ray department and involves radiation exposure. The test has limitations. If something abnormal is seen in the large bowel, a colonoscopy may still be needed to look at the area.

Preparing for the investigation

Bowel preparation

To reduce the risk of complications and to give clear views, your stomach and bowel must be empty. You will have been prescribed a laxative medication (also called ‘bowel preparation’) which will cause you to pass watery stools. Please follow the instructions in the ‘How to take your bowel preparation’ booklet. This contains instructions for the different types which vary depending on your appointment time. It is important to read the information and instructions several days before your procedure as there is dietary advice to follow.

If you have not received the booklet, please contact any of the booking teams (numbers are given on page 2 of this booklet) or access online at www.ulh.nhs/services/endoscopy

If, since the laxative was prescribed for you, your health has become worse in any way or you feel you will not be able to drink the amount of fluid advised, please contact the endoscopy department before you start taking it. Numbers are given at the start of this booklet.

What if I take regular medication?

If any of your regular medication needs to be stopped before the procedure, the person who booked the test should have discussed this with you. Most medication should be continued as normal, however, you must try to take it at least one hour before or after the laxative. If you are taking the oral contraceptive pill, you should take other precautions for the week following your test.

If you are taking iron tablets you should stop these at least 5 days before the procedure (7 days if possible). If you are taking Fybogel, Regulan, Proctofibe, Loperamide (Imodium), Lomotil or Codeine, please stop taking these at least 3 days before.

If you rely on strong pain killers which cause you to become constipated and you would find it difficult to stop them before the test, please take a daily laxative for a few days before you start taking the bowel preparation.

Blood thinning medications (anticoagulants)

Sometimes these medications need to be stopped and if this is the case the person who referred you for the test should have given you clear instructions. If you are unsure, please contact your consultant’s secretary. For your safety, if the correct instructions are not followed, it may not be possible to do the colonoscopy, and you may have to return on another day.

The risks of stopping blood thinning medications will vary enormously between individuals and depend on many factors including the medical condition for which you are taking them, other health problems, and the duration and complexity of the procedure. The main risks of stopping blood thinners are:

• Risk of stroke or systemic embolism (blood clot in artery to the brain, limbs or intestines)
• Risk of deep vein thrombosis and/or pulmonary embolism (blood clot in leg veins or to the lungs)
• Risk of blood clot on your artificial mechanical heart valve
• Increased risk of excessive bleeding following your procedure due to restarting your anticoagulant

Warfarin: Biopsies can safely be taken without stopping Warfarin so unless you have been advised to stop this medication, continue taking it and have your INR checked within the week before the test. The procedure may be cancelled if your INR has not been checked within the last 7 days. It should be within your target range.

If you have been advised to stop your Warfarin you should do so for 5 full days before the procedure (take your last dose 6 days before) and have your INR checked the day before the procedure. It needs to be less than 1.5 for the procedure to go ahead.

IMPORTANT: please bring your yellow book to the appointment.

Dabigatran, Rivaroxaban, Apixaban or Edoxoban: For biopsies to be taken please omit (do not take) on the morning of the procedure. If you have been advised to stop taking this medication you should take your last dose 3 days before the procedure.

Clopidogrel (Plavix), Prasugrel or Ticagrelor: Biopsies can safely be taken and small polyps removed without stopping these medications. If you have been advised to stop, you should do so for 7 full days before the procedure (take your last dose 8 days before).

Diabetes

If you have diabetes controlled on insulin or tablets, please tell the booking team and follow the instructions in the separate leaflet ‘Guidance for people with diabetes when taking bowel preparation’ about adjusting your medication, or contact your specialist diabetes team. If you have type 2 diabetes managed by diet alone, you do not need to take any extra precautions.

Conscious sedation

Conscious sedation is often given for this procedure to improve your comfort and is generally administered with a pain killer into a vein in your hand or arm. This will not make you go to sleep but should help you feel more relaxed.

It is important that you are awake for the procedure so that you can change position if required and tell us if you feel any discomfort.

Some people prefer not to have a sedative or pain killer for the test. If you wish to start the procedure without intravenous medication you may do so. It can be administered part way through the test if you feel you need it. Because it is given into the vein, it works within a few minutes.

‘Gas and Air’ (Nitrous Oxide) is also available for pain relief. This is a gas that you inhale through a mouthpiece and can be used in addition to, or instead of, medication into the vein. If you have Nitrous Oxide you will need to wait for at least 30 minutes before you can return to normal activities such as driving. If you would like more information, please ask the admitting nurse.

Please note if you have sedation into the vein, you will need someone to accompany you home and stay for at least 4 hours and if possible, overnight. You should not take public transport after having sedation and will not be able to drive yourself home.

You should not take part in the following activities for 24 hours afterwards:

• drive a motor vehicle or ride a bicycle (your insurance is affected)
• operate any type of electrical or mechanical equipment/machinery, including a cooker
• drink alcohol or take recreational drugs
• sign legally binding documents

We strongly recommend that you do not look after children or dependant relatives on your own for 24 hours after sedation.

What happens when I arrive?

When you arrive for your appointment please book in at reception.  It is our aim for you to be seen as soon as possible after your arrival. However, if the department is very busy your appointment may be delayed. The department looks after emergency patients who will be seen first if needed.

A nurse will take you through to the admission room and ask you about your general health to check if you are fit to have the procedure. You will also be asked about your plans for getting home afterwards.

The nurse will make sure you understand the procedure and discuss any further concerns or questions you may have. If you are happy to go ahead, you will be asked to sign your consent form.

Your blood pressure and heart rate will be checked, and you will be asked to remove your lower clothes and put on a hospital gown. You will also be provided with paper ‘dignity shorts’ which have a split at the back to allow access to insert the scope. Sometimes it is necessary to cut or tear the shorts a little, before or during the procedure, to ensure the endoscopist has adequate access.

A cannula (small plastic tube) will be inserted into a vein so that medication can be given during the procedure (sometimes this is done in the procedure room).

If you have sedation for the procedure, you will not be able to drive afterwards, and it is advisable not to use public transport. It is essential that you arrange for someone to collect you from the endoscopy unit. Please give the nurse their telephone number so that we can ring them when you are ready to go home.

What will happen during the procedure?

The nurse will take you through to the procedure room where you will be able to ask any final questions. A blood pressure cuff will be placed on your upper arm (this will be checked regularly throughout the procedure) and an oxygen monitoring probe on your finger. You will be asked to lie on your side with your knees bent. You will receive oxygen through the nose and if you are having sedation, it will be given into the cannula in your vein.

The endoscopist will usually examine your back passage with a gloved finger before inserting the scope. The bowel has natural bends which may cause some discomfort or tummy ache, but this is usually well tolerated and should not last long. You may also feel bloated due to the gas that is used.

You may be asked to change your position during the procedure as this can help with the passage of the scope.

What happens after the procedure?

After the procedure you will be taken through to the recovery area where you will be allowed to rest. Your heart rate, oxygen levels and blood pressure will continue to be monitored and when the recovery nurse feels you are ready you will be able to get dressed. You will be given a drink and a biscuit before the cannula is removed.

Before you leave the department, the nurse or doctor will explain the findings and if any medication or further tests are required.

You may feel some mild to moderate windy pains in your abdomen (tummy). Although these may be unpleasant, they are normal and should stop within 24 hours. If you had a polyp removed or a biopsy taken, you may see a little bleeding from your back passage.

If you have not had sedation, you may feel able to return to work after the procedure depending on the sort of work you do. Some people need time to rest at home afterwards. By the following day most people feel able to resume normal activity. If you have been given sedation you are advised not to return to work for 24 hours afterwards.

What happens if a polyp is found?

A polyp is an overgrowth of cells on the inner lining of the bowel. Polyps may be raised on a stalk like a mushroom (pedunculated) or flat (sessile). Polyps are generally removed or sampled (biopsied) by the endoscopist as they could grow over time and cause problems in the future. This does not cause any pain.

Polypectomy (removal of a polyp)

Polyps with a stalk are usually removed using a wire loop (snare) which is placed around the stalk. Heat is passed through the wire which cuts through and cauterises any blood vessels. Flat polyps are often removed by injecting the tissue around the polyp with fluid to raise the area away from the deeper layers. A hot wire snare is then used to remove the polyp.

Smaller polyps may be removed with a cold wire snare or pinched off the bowel wall with forceps. Polyps are sent to the laboratory to be looked at under a microscope. Your consultant may write to you with the results or give them to you at your next clinic appointment if you have one. You may also contact your GP. Routine results are usually available within 4-6 weeks but can sometimes take a little longer.

What are the risks of removing polyps?

After removal of a polyp there is a risk of bleeding and/or a hole forming in the bowel wall while the area heals. The healing process can take up to 2 weeks. It is advisable not to travel abroad for this period if large polyps are removed. Please tell the nurse or doctor if you have plans for travel after your procedure.

In most cases you can resume normal activity afterwards but if you have a large polyp removed you may be advised to avoid heavy lifting or strenuous exercise for 2 weeks to reduce the risk of complications. It is important to attend the accident and emergency department if you pass any fresh blood or clots (more than a few tablespoons) or if you have severe pain and swelling in the abdomen (tummy) which persists and does not get better.

What must I remember?

• If you are unable to keep your appointment, please notify the endoscopy department as soon as possible. Telephone numbers are given at the beginning of this booklet.

• Follow the instructions for taking the bowel preparation found in the ’How to take your bowel preparation’ enclosed. If you are unsure, please contact the endoscopy unit on the numbers on page 2 of this booklet.
• It is our aim for you to be seen as soon as possible after your arrival. However, the department is very busy, and your appointment may be delayed. If emergencies occur, these patients will be seen before less urgent cases.
• If you have opted for sedation into the vein, please arrange for someone to collect you and for someone to stay overnight if possible. Your activities afterwards are limited for 24 hours (more details are given in the section on sedation).
• The hospital cannot accept any responsibility for the loss or damage to personal property during your time on the premises.