CONSENT Upper GI Endoscopy



Upper GI Endoscopy is a visual examination of the oesophagus, stomach and duodenum. A long flexible endoscope is passed through the mouth into the oesophagus, stomach and first half of the duodenum. A detailed image of the upper gastrointestinal tract is then projected on a screen to allow any abnormalities to be visualized. If necessary, small tissue samples (biopsies) can be taken during the examination for pathological analysis. Polyps are benign tumours which may have cancerous potential. They can usually be removed at endoscopy using an electric snare wire.

A number of other treatments can also be performed through the endoscope.  These include but are not limited to stretching (dilatation) of narrowed areas of the oesophagus, stomach or duodenum, removal of swallowed objects, and treatment of bleeding blood vessels often associated with ulcers by injection, heat therapy or the application of clips.

If any of the other treatments listed above are performed during the procedure as the doctors deem necessary, there may be extra charges applicable for uninsured patients.


You must advise The Gastrointestinal Centre at the time of your booking if you are taking any blood thinning medications. This includes asprin, warfarin, plavix and iscover. You will be advised as to whether any changes with these medications are necessary.


Appointment Before 12.00 pm – No solid food from midnight but clear fluids can be consumed up to 3 hours prior to your appointment. YOU MUST REMAIN NIL BY MOUTH FOR 3 HOURS PRIOR TO APPOINTMENT.

Appointment After 12.00 pm – 6.00 am Breakfast of tea and toast only followed from 6.30 am by clear fluids which can be consumed up to 3 hours prior to your appointment. YOU MUST REMAIN NIL BY MOUTH FOR 3 HOURS PRIOR TO APPOINTMENT


You will be placed in a comfortable position on your left side and will be given medication by injection through a vein to send you to sleep. In the unlikely event that you feel any discomfort, further sedation will be provided. The doctor will pass the endoscope through your mouth and down through the oesophagus, stomach and duodenum. The examination usually takes 10-15 minutes. You should allow approximately 4 HOURS for your total hospital stay. You should bring a book or magazine as delays may occur despite our endeavours to avoid them. They usually relate to a greater period of time than expected being required for individual patients.


You will be transferred to the recovery area where you will remain until the effects of all medication have worn off. You may experience some wind discomfort following the procedure although this usually passes quickly. A light snack is provided.

A companion MUST be able to drive or accompany you home as the sedation impairs your reflexes and judgement. For the remainder of the day you should not drive a car, operate machinery or make important decisions. We suggest that you rest quietly. You may return to your regular diet unless otherwise instructed.


Upper GI endoscopy can result in complications although they are rare for simple inspection of the upper gastrointestinal tract. The overall incidence rate is less than 1 in 1,000 examinations. These complications include reactions to medication, perforation of the upper gastrointestinal tract and bleeding. The risks are higher when the endoscope is used for interventional treatment including the removal of polyps or with oesophageal dilatation.

Cancer of the upper gastrointestinal tract may rise from pre-existing benign polyps. It is advised that if polyps are found at the time of the examination, they should be removed to prevent their possible change to cancers. On occasions polyps may already be malignant. Polypectomy is achieved by placing a snare wire around the base of the polyp and using an electrical current to transect the stalk of the polyp.

Following polypectomy, bleeding may occur from the polyp site or rarely a perforation of the upper gastrointestinal tract may occur. If you are taking blood thinning medication, this risk is increased. These complications are rare with the benefits of upper GI endoscopy and polypectomy being significantly higher than the risks involved.

If you experience any significant pain, black tarry stools or persistent bright bleeding in the hours or up to 7 to 10 days following upper GI endoscopy +/- polypectomy, you should immediately contact The Gastrointestinal Centre or the hospital where your procedure was performed. If a significant haemorrhage occurred, a blood transfusion may be required. The source of any continued bleeding can usually be managed by another endoscopic procedure.

The greatest risk of perforation occurs with the performance of oesophageal dilatation. This is routinely performed with the aid of a guidewire and an image intensifier to aid visualization of the instruments during the procedure. Bleeding may occur although this usually settles with conservative observation. Perforation is the principal complication which may require an urgent abdominal/chest operation and admission to the hospital intensive care unit. This particular complication will have already been discussed with you by your doctor if an oesophageal dilatation is to be performed.

Complications of sedation are uncommon and are usually avoided by administering oxygen during the procedure and monitoring oxygen levels in the blood. In patients with severe cardiac or respiratory disease, serious sedation reactions can rarely occur.

Both benign polyps and cancerous lesions may be missed although upper GI endoscopy remains the best way of identifying these abnormalities. Death is a remote possibility with any interventional procedure.

You are welcome to attend for a consultation at an earlier time prior to your procedure if you wish to discuss the potential complications of upper GI endoscopy in more detail. If on the day of your procedure you have any reservations or wish to discuss these matters further, please advise the Admissions Sister before your procedure. Your doctor will be pleased to discuss these matters with you.

You are advised that you should not drive a car, operate machinery return to work or sign legal documents for a period of 12 HOURS following your procedure.


You MUST advise The Gastrointestinal Centre immediately if you:

are diabetic taking either tablets or insulin
take Warfarin, Coumadin, Plavix, Iscover, Aspirin or any other blood thinning medication
may be pregnant

I hereby consent to the use of my personal information for the purposes indicated below:

To assist other medical practitioners or institutions who may treat me in the future but only to the extent necessary to treat the particular condition for which I have consulted at The Gastrointestinal Centre. This may include a requirement to forward relevant prior information including anaesthetic records.

To inform next of kin identified in my admission form of the outcome of treatment or to obtain consent to necessary treatment when I am not able to provide such consent.

To enable The Gastrointestinal Centre to provide access to my information to the health fund of which I am a member if requested by the health fund.

To enable The Gastrointestinal Centre to obtain any medical records including pathology and radiology results.

I have read and understand the procedure description overleaf and agree to an upper GI endoscopy being performed. I agree to the removal of any polyps and the taking of biopsies if considered appropriate by the doctor at the time of the procedure.

I agree to the performance of an oesophageal dilatation only if this procedure has been previously discussed in detail with my treating doctor.

NAME: …………………………………………………………(Please print)

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