CONSENT Capsule Endoscopy

CONSENT AND INSTRUCTIONS FOR SMALL BOWEL CAPSULE ENDOSCOPY  

THE PROCEDURE

Capsule endoscopy for the small bowel involves swallowing a camera the size and shape of a large antibiotic capsule. This camera takes 3 photos per second as it travels through your digestive system in the same way food would. The capsule is disposable and passes within approximately 48 hours and can be flushed down the toilet. The photos of the digestive tract are transmitted to a recording receiver worn on the waist. This recorder m

ust be kept on for the duration of the test (Approx 8 hours). This recorder is returned and the pictures are then analysed by your doctor.

This test allows visualisation of parts of your digestive tract that cannot be reached by gastroscopy or colonoscopy and does not replace these tests. This test takes pictures only and does not treat any disease that it may encounter.

PREPARATION
To ensure a clear view Iron tablets should be stopped at least 7 days before the test.

DAY BEFORE THE PROCEDURE
Have a normal lunch, then commence on clear fluids.
Clear Fluids;
Jelly (NO RED, GREEN, OR PURPLE)
Clear apple juice
Water
Cordial (NO RED, GREEN, OR PURPLE)
Clear soup
Clear soft drink
At 6pm dissolve the entire contents of Picoprep into a glass of water and stir well. This is to be consumed followed by another glass of water. You must continue on clear fluids after taking the prep. A high intake of clear fluids is advised.
Only water may be ingested during the 12 hours leading up to swallowing the capsule endoscope.

ON THE DAY
Wear comfortable and loose clothing and do not apply lotions or perfumes.
Arrive at clinic at pre-determined time in the morning for placement of receiver and ingestion of the capsule.
Patient should drink 250ml of water per hour during the procedure.
Four hours after ingesting the capsule, the patient may have a light lunch. The patient may have a normal meal 8 hours after the ingestion of the capsule.
Return receiver to the clinic at the specified time.

RISKS
Capsule endoscopy can result in complications. Approximately 1 in 100 patients can have the capsule get stuck due to a narrowing of the digestive tract from inflammation, large polyps or scarring from previous surgery. This is usually not a serious concern in the short term but can require a gastroscopy or surgery to remove the capsule. If you have Crohns disease or previous gastrointestinal surgery, please notify your doctor. If after reading capsule images if the doctor is concerned about possible capsule retention you will be contacted by phone. It is sometimes necessary to have an abdominal x-ray to exclude capsule retention.

Small bowel disease, growths, and polyps may be missed, but capsule endoscopy is currently the best test available to visualise the small bowel. Variations in patient intestinal motility may result in not all of the small bowel being visualised. This may require a repeat test.

Due to the material in the capsule we ask patients to avoid MRI machines until the capsule has passed. It is safe for patients with pacemakers or defibrillators.

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 the doctor 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 obtain any medical records including pathology and radiology results.

I have read and understand the procedure description overleaf and agree to a capsule endoscopy being performed.

I have discussed the procedure with Dr …………………………………… I understand the risks, benefits and alternatives.

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

SIGNATURE: …………………………………………………………..… DATE: ……………………………………