From the practice of Dr. Gideon Shaw and Dr. Brimli Rasaratnam 301 Blackburn Road, Mt. Waverley, 3149 Te/:98030
Please read the following information carefully.
WHAT IS THE PROCEDURE? The colonoscope is a thin flexible tube, about the thickness of a finger for examination of the large bowel. After you have been given intravenous sedation the tube is inserted gently and moved inside the large bowel up to the junction with (and sometimes into) the small bowel. In about 5% of patients only part of the bowel can be jnspected due to variation in the structure of the bowel or technical difficulty. Several procedures can be carried out through the colonoscope including taking small tissue samples (biopsy) and removal of polyps. ALTERNATIVES TO COLONOSCOPY
An alternate method of examining the large bowel is barium enema but this is generally
considered to be less accurate and does not allow taking of biopsy samples or removal of polyps (growths in the bowel).
HOW CAN YOU HELP? Although colonoscopy is the best way of assessing abnormalities of the large bowel there is still a small chance that abnormalities are not seen, especially when the preparation is poor. Before the procedure, the bowel will need to be emptied to allow proper examination. If the bowel is not adequately emptied the procedure may have to be abandoned and repeated at a later stage. Therefore it is essential that you follow the instructions carefully to empty the bowel. The bowel preparation required for your examination is enclosed on a separate form. WHAT SHOULD YOU TELL US? Please inform either the medical or nursing staff if you are sensitive (allergic) to any drugs or substances. You should also notify the doctor if you have been taking blood thinning tablets (Warfarin or Coumadin) or are taking any form of aspirin (this also includes Plavix or Iscover). If you have any doubt about the medication that you are, taking, please discuss this with the doctor before the procedure. Aspirin must be ceased at least seven days before the procedure to minimize any risk of bleeding. In addition, if you have heart valve disease or a pacemaker, this must be brought to the attention of the doctor. You will be sedated for the examination and will remain sedated for some time following.
Cancer of the large bowel may arise from pre-existing polyps; therefore it is advised that if any polyps are found they should be removed at the time of examination to prevent risk of cancer. Most polyps can be burnt off by placing a wire snare around the base and applying an electric current. At the time of examination you will be sedated and it is therefore not possible to discuss the removal of the polyp with you. If you have any reservation regarding removal of a polyp you must discuss this matter before the colonoscopy with the doctor. ARE THERE ANY RISKS INVOLVED?
Any medical procedure is associated with some risk, but examination of the colon is considered a safe procedure with most surveys reporting complications in 1 in 1000 examinations or less. The following information is not to cause undue alarm or anxiety, but simply to make you aware of potential complications and how they may be managed.
• Some patients may experience intolerance of the bowel preparation solution such as
nausea or vomiting. This is easily managed by taking the preparation at a slower rate or having a short break allowing time for the preparation to result in a bowel movement.
• Occasionally a patient may have a reaction to the sedatives used at the time of
examination, but these reactions are managed by the anaesthetist during the procedure.
• Perforation (puncture or hole in the bowel) is a rare complication with estimated risk being
1 per 2000 if no extra procedures are performed, and 1 per 1000 if polyps are removed. If this does occur, surgery may be required to repair the defect. Rarely, there may be a need for a colostomy (external bag). .
• Bleeding - this generally is insignificant but very rarely patients may require a blood
transfusion, repeat procedure to stop bleeding, hospitalisation or even surgery to stop bleeding. Patients who are on medications such as aspirin (or similar drugs), Warfarin, anti-platelet drugs or antiinflammatory drugs have increased risk of bleeding. Hence it is important to stop these medications (after discussion with your doctor), a satisfactory time prior to the procedure. The estimated risk of bleeding with biopsy is 1 per 3300 and with removal of polyp is 1 per 500 procedures.
• Colonoscopy is recognised to be the most accurate way of visualising the colon but even so,
there is a very small chance that polyps or cancers are missed. This risk is increased if the bowel preparation is inadequate.
• The instrument is very meticulously manually and machine cleaned between patients.
Rarely the residue from instrument cleansing agents can cause inflammation of the inner lining of the bowel which may cause diarrhoea and bleeding. This may require treatment.
• Death - although incredibly rare, is a possible consequence of any medical procedure.
WHAT CAN I DO AFTER THE COLONOSCOPY? You will have a cup of tea or coffee after the procedure. Further instruction will be given to you regarding what you should do in the following 24 hours after colonoscopy. The sedatives given at the time may impair your memory and therefore it is important that you not undertake any important transactions, drive or operate machinery where there may be a risk of personal injury. It is important that you are accompanied home by a relative or friend. If you have any severe abdominal pain, bleeding, fever or any other symptom that causes you concern following the procedure, you should contact Dr Shaw or Dr. Rasaratnam immediately, or alternatively discuss the concern with your family doctor. I have read the above information and have been given the opportunity to discuss the procedure with the doctor. I understand I can cancel the procedure at any time if I am not happy to proceed I request the procedure now be undertaken.
(Do not sign until you speak with the doctor) Date:
Strategies for subtypes—dealing with the diversity ofbreast cancer: highlights of the St Gallen InternationalExpert Consensus on the Primary Therapy of EarlyBreast Cancer 2011A. Goldhirsch1*, W. C. Wood2, A. S. Coates3, R. D. Gelber4, B. Thu¨rlimann5, H.-J. Senn6 & Panelmembers 1International Breast Cancer Study Group, Department of Medicine, European Institute of Oncology, Milan, Italy;
Corporate Alcohol and Drug Standard for EmployeesThe purpose of this standard is to outline the expectations associated with alcohol and drug use, and confirm TransAlta's commitment to manage risk associated with our operations. TransAlta reserves the right to enforce, change or amend the requirements within this standard, at any time. Application The following provisions apply to