Informed Consent for Esophagogastroduodenoscopy (EGD)

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Informed Consent for Esophagogastroduodenoscopy (EGD)

Patient and Procedure Information

Nature and Purpose of the Procedure

An upper endoscopy, also known as esophagogastroduodenoscopy (EGD), is a diagnostic procedure performed to examine the lining of your esophagus, stomach, and duodenum (the first part of the small intestine). Under sedation, a thin, flexible tube called an endoscope, equipped with a light and a tiny camera, is gently passed through your mouth and down your throat. The physician views the high-resolution images on a monitor to identify inflammation, ulcers, tumors, bleeding, or other abnormalities. If indicated, the physician may take tissue samples (biopsies), remove polyps, or perform therapeutic interventions such as dilating a narrow area or stopping active bleeding. The examination itself typically takes 15 to 30 minutes, though preparation and recovery time require you to remain at the facility for 2 to 3 hours.

Biopsy and Polypectomy Authorization

I authorize the physician to perform tissue biopsies (removing small skin-like samples of the lining) during the procedure as clinically indicated for laboratory diagnosis.
I authorize the removal of gastrointestinal polyps (small growths on the lining) if discovered. I understand that removing polyps reduces the risk of future abnormalities but slightly increases the risk of local bleeding.
I authorize the submission of all collected specimens to a certified pathology laboratory for histopathology review. I understand pathology results take approximately 3 to 7 business days to complete.

Material Risks and Potential Complications

Bleeding: minor bleeding can occur at the site of a biopsy or polyp removal. In most cases, it stops on its own or is controlled during the procedure. In rare cases, a blood transfusion or repeat procedure may be needed.
Perforation: a very rare but serious complication in which a tear or hole is made in the wall of the esophagus, stomach, or duodenum. The risk is less than 1 in 2,500 diagnostic procedures, but higher if dilation or complex interventions are performed. A perforation requires hospitalization and often emergency surgery to repair.
Sedation risks: localized reaction at the IV site, temporary breathing slowing, drop in blood pressure, or irregular heartbeat. Oxygen levels are monitored continuously, and rescue medications are kept on hand.
Aspiration: inhaled saliva or stomach fluids into the lungs, which can cause lung irritation or pneumonia. Strict fasting before the procedure minimizes this risk.
Dental injury: rare, but pressure on teeth during scope insertion can cause injury, especially to loose teeth, bridges, or crowns. A protective mouthguard is worn throughout the procedure.
Infection: very rare. The endoscope goes through rigorous high-level disinfection processes between uses that meet all safety standards.

Pre-Procedure Fasting and Medication Rules

To ensure a safe procedure and a clear view of your stomach, you must strictly follow these instructions: (1) Do not eat any solid food for at least 8 hours before the procedure. (2) Do not drink any liquids, including water, for at least 4 hours before the procedure. (3) If you take blood thinners, diabetic medications, or insulin, confirm when to stop or adjust them with your doctor. (4) Take your essential morning blood pressure or heart medications with a tiny sip of water at least 2 hours before arriving.

Alternatives to Upper Endoscopy

Radiology studies: a barium swallow or upper GI series (X-rays taken after drinking a contrast fluid) can show structural changes but cannot take biopsies or remove polyps.
Non-invasive tests: stool tests or breath tests to check for H. pylori infection, which can help diagnose some stomach issues but does not check the physical lining.
Conservative treatment: starting acid-reducing medications based on symptoms alone, without diagnostic confirmation. This runs the risk of missing serious underlying conditions.

Post-Procedure Warning Signs

A sore throat, mild bloating, or gas are common for the first 24 hours. You must seek immediate emergency medical care if you develop any of the following symptoms after discharge: (1) Severe or worsening chest pain or abdominal pain, (2) Difficulty swallowing or severe throat pain, (3) Fever above 101 degrees Fahrenheit (38.3 degrees Celsius), (4) Chills, (5) Vomiting blood or material that looks like coffee grounds, (6) Black, tarry bowel movements, (7) Difficulty breathing or shortness of breath.

Discharge and Driver Verification

Because you will receive sedative medications, you cannot drive a vehicle, operate machinery, or go home alone by taxi or public transit. You must have a responsible adult (18 years or older) present at the facility to drive you home and remain with you for at least 4 hours after discharge. You are instructed not to make important legal or financial decisions for 24 hours following sedation.

Right to Refuse or Withdraw Consent

You have the right to refuse this procedure or withdraw your consent at any time before the endoscope is inserted. The gastroenterologist will explain the clinical consequences of not performing the procedure, such as a delayed diagnosis or worsening of untreated conditions.

Patient Understanding and Questions

I confirm that I have read this consent form and understand the purpose, risks, and alternatives of the upper endoscopy procedure. I have had the opportunity to ask questions of the gastroenterologist, and my questions have been answered to my satisfaction. I understand that no results can be guaranteed.

Language Access Services

If English is not your primary language or if you require assistance, a qualified medical interpreter is available to translate this document at no cost to you. Please inform the intake coordinator before signing.

Copy of Consent Acknowledgment

I acknowledge that I have been offered a copy of this signed consent form for my personal records.

Patient Authorization

I voluntarily consent to undergo an upper endoscopy (EGD) with any associated biopsies, polyp removals, or therapeutic treatments described in this document. I confirm that I have followed the fasting guidelines and have made arrangements for a responsible driver to take me home after the procedure.

Signatures and Verification

Patient / LAR Signature
Gastroenterologist Signature
Witness Signature
Date and Time of Consent
Document ID: CC-PENDING
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