Colonoscopy advice for patients / parents

Please remember, before leaving the hospital, to collect your bowel prep from outpatient pharmacy after your clinic appointment.

You will receive a phone-call from our pre-assessment unit before your child’s procedure. This is a scheduled telephone appointment and typically lasts for 20 minutes. Please note that your child’s procedure cannot go ahead if your child has not had a pre-assessment.

This information leaflet has been designed to guide you in preparing your child appropriately for their colonoscopy. Please read it carefully at least one week before the procedure, as some medication may need to be stopped.

Appropriate preparation:

• reduces anxiety for your child and yourself
• ensures complications are reduced
• allows completion of the procedure allowing diagnosis
• aids your child’s recovery

What is a colonoscopy?

A colonoscopy is a procedure that allows the doctor to look inside your child’s colon (the large bowel / intestine). The colon is the last part of the bowel where the final part of digestion occurs, water is absorbed and faeces (stools) are stored until being passed out of the anus (back passage). The procedure is undertaken with a narrow, flexible instrument that can be guided around the bowel.

Preparation

Information for bowel preparation before colonoscopy

This information leaflet provides you with a step-by-step outline of the bowel preparation regimen we use at Addenbrooke’s.

It is important that your child’s bowel is as clean as possible before their colonoscopy as this allows the endoscopist a good view of the bowel, helps make a diagnosis and reduces the potential risks of the procedure.

Please note that if your child’s bowel is not clear it may be necessary to cancel / postpone the procedure for at least a week. If your child is having difficulty taking the bowel preparation as instructed, please call the gastroenterology nurses by 13:00 (1pm) the day before the procedure.

Preparation of the bowel begins seven days before the procedure.

Seven days before the procedure

You should stop giving your child the following medications seven days before their procedure:

• loperamide (Immodium)
• codeine phosphate
• iron supplements
• Fybogel

Continue all other medications and laxatives. If in doubt please ask one of the team.

Two days before the procedure

Your child can eat foods from the ‘foods allowed’ list below and must not eat any foods in the ‘foods to avoid’ list.

Foods allowed

• Breads: White bread
• Rice, pasta and other grains: white pasta, white flour / cornflour, white pasta, white rice, noodles, couscous
• Breakfast cereals: Rice Krispies / Coco Pops, Cornflakes / Frosted flakes, Sugar Puffs
• Potatoes: boiled (no skin), mashed, baked, chips (no skin)
• Meat and fish and alternatives: all lean meat and fish, eggs, tofu
• Fruit: none
• Vegetables: none except potato (no skin)
• Beans and pulses: none
• Dairy: cheese, yoghurt and fromage frais (no fruit pieces), milk, custard, rice pudding, ice cream
• Crackers, cakes and biscuits: plain biscuits (for example Rich Tea), rice cakes, plain cake
• Sweet and savoury snacks: chocolate, crisps, sweets, jelly (not red), ice lollies (not red)
• Soups, sauces and spreads: soup (not tomato), gravy made from stock cubes (use flour or cornflour to thicken), jam and marmalade without pips or peel, yeast extract
• Fats and oils: butter, margarine, oil
• Sugars and sweeteners: All sugars and sweeteners
• Drinks: water, fruit juice (no bits), hot chocolate, Horlicks / Ovaltine, tea and coffee, fizzy drinks, herbal / fruit tea, sports drinks (for example Lucozade), squash

Foods to avoid

• Breads: Bread with seeds, wholemeal and granary bread
• Rice, pasta and other grains: brown rice, wholewheat pasta, wholewheat noodles, wholewheat couscous
• Breakfast cereals: porridge, muesli, wholegrain breakfast cereal (for example Weetabix, Shreddies), cereal containing fruit or nuts (for example Fruit and Fibre, Crunchy Nut)
• Potatoes: potato with skin
• Meat and fish and alternatives: quorn
• Fruit: all fruit
• Vegetables: all vegetables, beetroot
• Beans and pulses: all pulses (for example, beans, lentils, peas)
• Dairy: dairy foods containing fruit pieces or nuts
• Crackers, cakes and biscuits: biscuits and cake containing fruit or nuts, oatcakes, flapjacks, Ryvitas, wholemeal crackers / biscuits (for example Digestives)
• Sweet and savoury snacks: chocolate containing fruit or nuts, nuts and seeds, red jelly and ice lollies
• Soups, sauces and spreads: vegetable soups, jam and marmalade with pips or peel, peanut butter, hummus
• Fats and oils: none
• Sugars and sweeteners: none
• Drinks: fruit juice with bits, red fruit juice, smoothies, red soft drinks (for example Cherryade)

One day before the procedure

Please follow the instructions below as appropriate depending on whether your child is on the morning or afternoon list.

Your booking letter will confirm what list your child is on.

Morning list: Ensure your child has a good breakfast before 07:00am, choosing only food from the ‘food allowed’ list above.

Afternoon list: Ensure your child has a good breakfast before 09:00am, choosing only food from the ‘food allowed’ list above.

After this do not allow your child to eat any more solid food, and encourage them to drink as much fluid as possible. The following are allowed:

• water
• clear sports drinks*
• clear soup (no lumps)*
• diluted squash*
• jelly*
• tea and coffee (no milk)
• clear apple juice
• boiled sweets*
• ice lollies*

*Avoid those red in colour as they may stain the bowel.

Drinks

Your child should have a minimum of two to three litres (about four to six pints) to drink in the 24 hours before the procedure to avoid dehydration. If your child looks dehydrated, feels dizzy or urinates less than usual please seek medical advice. The laxatives do not work effectively if no fluid is taken, so the more your child can drink the more effective the preparation.

Top tip: So that your child does not get bored, try to vary their drinks and don’t forget jellies, soups and ice lollies – as long as they are not red – are included in the fluid total!

09:00

• Give your child the Senokot liquid / senna in one dose with a drink.
• Senokot is a strong stimulant laxative that works by stimulating the bowel; this can cause some crampy tummy pain.

13:00

• Dissolve the sachet of Picolax in half a cup of water and ensure your child drinks this over the next 10 to 20 minutes (perhaps use fruit squash to flavour it). Over the next 40 minutes ensure your child drinks at least a further cupful of fluid.
• Encourage your child to drink at least two litres (about four pints) of fluid before 18:00 (6pm) and more if possible.

Frequent bowel actions and diarrhoea may occur within three hours of this dose so ensure that your child is near a toilet once they have taken the Picolax.

Some children vomit after taking the Picolax. Unless the vomiting is excessive, do not worry; it still works.

17:00

• Dissolve the second sachet of Picolax in half a cup of water and drink over the next 10 to 20 minutes (perhaps use fruit squash to flavour it). Ensure that your child drinks at least a further cupful of fluid in the next 40 minutes.
• Encourage your child to complete a total of at least two to three litres (four to six pints in total) of fluid before bed.
• If your child wakes overnight, encourage them again to drink more.

The Picolax works by increasing the activity of the bowel and by holding water in the bowel, which helps to wash it out; this is why it is important to encourage your child to drink plenty of liquid.

When mixing the Picolax it is important to be careful as the liquid becomes very hot and can cause a burn. Make it up in half a glass of water, allow it to cool to room temperature, and then give it to your child together with a glass of water, both to be drunk over the next hour.

Your child may have a tummy-ache after taking these laxatives, but you can give them paracetamol, use a hot water bottle, give peppermint tea or cordial, or massage the painful area.

Your child’s bottom may become sore. Use of a barrier cream such as Sudocrem or Vaseline may help.

You may use the following chart to help you keep track of the drinks and medicine you give in the 24 hours before the procedure.

Please follow table as per morning list (AM) or afternoon list (PM).

Please check your booking letter to confirm which list your child is on.

One day before the procedure

7:00 - AM list, stop diet

9:00 - PM list, stop diet, Senokot

13:00 - Picolax

17:00 - Picolax

2:15 - AM list, clear fluid only

7:15 - PM list, clear fluid only

6:00 - AM list, last drink (water)
Please ensure your child has this drink. Further fluid allowance will be advised by the ward.

11:00 - PM list, last drink (water)
Please ensure your child has this drink. Further fluid allowance will be advised by the ward.

On the day you will be informed of an estimated time for your child’s procedure.

Morning list: 08:00am to 12:00pm

Afternoon list: 13:30 to 17:15

Your booking letter will confirm if your child is on the morning or afternoon list.

Your child is only allowed jelly, soup, etc. for 24 hours before their procedure; that is, after breakfast the day before.

It is very important that the bowel preparation is effective, as otherwise we may need to cancel the endoscopy or be unable to obtain all the necessary information.

Morning of the procedure

Please follow instructions below for if your child is on the morning or afternoon list. Your booking letter will confirm what list your child is on.

Morning list

Clear fluids (water or very dilute squash) only should be taken this morning. No food of any kind. All fluids should be stopped at 06:00am.

On the day of the procedure your child will be seen on Ward F3 by the doctors, anaesthetist and nurses to prepare them for the procedure.

If your child’s bowel is not clear by 07:30am it may be necessary to postpone the procedure.

Afternoon list

Clear fluids (water or very dilute squash) only should be taken this morning. No food of any kind. All fluids should be stopped at 11:00am.

On the day of the procedure your child will be seen on Ward F3 by the doctors, anaesthetist and nurses to prepare them for the procedure.

If your child’s bowel is not clear by 12:30am it may be necessary to postpone the procedure.

Getting ready for the procedure

On arrival, the procedure will be explained again to you and your child and the paediatric endoscopist will ask you to sign a consent form. You and your child will also be seen by the anaesthetist as your child’s procedure will be carried out under general anaesthetic. If your child wishes, they can have a special cream applied to the back of their hands which numbs the sensation in this area. This is in preparation for inserting a cannula (a very thin plastic tube that sits in the vein and allows medicines or fluid to be given directly into your child’s body).

You will be asked to wait in the pre-procedure area until it is time for the procedure. Your child will need to undress and put on a gown, so it is a good idea to bring their slippers and a dressing gown for them to wear while they are waiting.

During the procedure

The procedure is undertaken with a colonoscope (a narrow, flexible instrument that can be guided around the bowel), which is passed into the anus, through the colon and into the terminal ileum (the lower part of the small bowel). The lining of the bowel is checked to see if there are any problems such as inflammation or polyps. (A polyp is a bit like a wart). The colonoscopy procedure usually takes around thirty minutes, but you should not worry if it takes longer as times can vary considerably.

To help establish your child’s diagnosis, about six biopsies will be taken. A small instrument, a forceps, is passed through the colonoscope to pinch out a tiny bit of the lining (two to three millimetres across, about the size of a pinhead) which is sent to the laboratory for analysis.

What are the benefits of the procedure?

Your doctor should have discussed the likely benefits of the procedure with you and your child. If you are not sure how this procedure is likely to benefit your child’s health, please ask one of the medical team; they will be happy to explain this to you. In most cases, the procedures are done to try and help make a diagnosis, that is, to work out the cause of your child’s symptoms and therefore allow better treatment for your child.

Alternatives

The colonoscopy is still the only test that will actually allow your doctor to see the lining of your child’s bowel and take biopsies. Both of these are necessary to confirm or rule out the diagnosis. The colonoscopy is the most sensitive test to establish the condition of your child’s large bowel. Although there are x‑ray tests and scans available, these do not give the same amount and type of information. Your child’s doctor should have discussed the reason this procedure needs to be done, and explained why alternative tests were not suitable. If you have further questions, please ask your doctor.

Potential problems

Colonoscopy procedures carry a small risk (less than one in 1,000 cases) of haemorrhage (bleeding) or perforation (tear) to the bowel if your doctor is only taking pinch biopsies. The risks are slightly greater if some form of treatment is required (for example, removal of a polyp, dilatation of a narrowing [stricture]). These risks will be discussed with you separately. The risk of serious infection is so low that we do not routinely give antibiotics before a procedure. All the equipment is cleaned according to national standards set out by the British Society of Gastroenterology. Another rare complication is an adverse reaction to the general anaesthetic, but your child’s anaesthetist will discuss this with you. Rarely, the tissue samples taken during an endoscopy may be too small, or too damaged, during processing to make a definite diagnosis. In certain cases it may then be necessary to repeat the procedure.

After the procedure

Following the procedure, your child will be taken to a recovery area to recover from their general anaesthetic. Once they have recovered, the nurse will call one parent in to the recovery area. This will not be long after their procedure is complete. When sufficiently awake, your child can have a drink, followed by something to eat if they are not feeling sick. They will need to have eaten and drunk something before being discharged home.

Your child may feel bloated and have some crampy, wind-like pains as some of the air used during the procedure remains in their bowel. This usually settles down over the next 24 hours. Your child may be tired and a little clumsy or unsteady for around 24 hours after the test, so do not allow activities that could lead to a fall. He or she may also seem very grumpy for the first few days. This is a side effect of the anaesthetic and does not last long. You will be given a leaflet of what you can expect in the days immediately after your child has had their procedure. Please read this leaflet carefully.

When you get home, you can give your child regular pain relief, every four to six hours for the first 24 hours and then as often as he or she seems to need it, to ensure they can eat or drink. The nurses on the ward will tell you when your child can have the next dose before you go home. Always follow the instructions on the bottle. You do not need to wake your child up during the night to give a dose.

Usually, paracetamol, like Calpol®, will provide sufficient pain relief. If you believe your child requires stronger painkillers this can be discussed with the medical team.

If, when you get home, you feel that your child needs stronger pain relief, you should call your GP or the gastroenterology nurse specialists (on the telephone number below) for advice. If necessary, please leave a message and we will call you. If you are concerned after 16:00, please contact A&E or the out-of-hours service. The healthcare professional can call Addenbrooke’s Contact Centre (01223 245151) and ask to contact the paediatric gastroenterology nurse specialists during working hours or the on‑call paediatric registrar out‑of-hours.

Your child should be able to go back to school 24 hours after the procedure.

When do I know the result?

The endoscopist will be able to tell you what they were able to see before you go home. They will also discuss a plan for your child’s further management.

The biopsies will usually take seven days to be fully reported on. A member of our team will then call you as soon as we have the results to pass these on to you and, if necessary, adjust your child’s treatment plan. A letter confirming the findings of the procedures and management plan will be sent to you, your child’s GP, your referring consultant and any other healthcare professionals involved in your child’s care. If you do not wish anyone involved in your child’s care to receive this information, please let one of the team know.

Training

Training doctors and other healthcare professionals is essential to the continuation of the National Health Service and improving of the quality of care. Your child’s treatment may provide an important or unique opportunity for such training under the careful supervision of a senior doctor. You or your child can, however, decline to be involved in the formal training of medical and other students; doing so will not affect their care and treatment. Please ask your consultant or specialist nurse if you have any questions about this.

If you are concerned, or your child has any of the symptoms below:

• severe pain
• fever – temperature higher than 38.5°C for more than two hours (not responding to paracetamol)
• black, tarry stools
• persistent rectal bleeding

… please contact the one of the following:

• gastroenterology nurses 01223 348950, 08:00am until 16:00
• your GP and local A&E, 16:00 until 08:00am

or

• Addenbrooke’s hospital: 01223 245151 (ask to speak to the on‑call paediatric registrar).

Children's anaesthesia

Children may need anaesthetics for operations, just like adults. They may feel distressed, and their parents can feel anxious. Anaesthetists recognise this, and do their best to keep distress to a minimum. These days, children usually come into hospital on the same day as the operation, unless it is major, and do not usually have pre-meds. They are seen with their parents by their anaesthetist and usually have local anaesthetic cream put on their hands at this point as described previously.

It is usual for one parent to stay with their child while they are being anaesthetised, in case they get scared. Many anaesthetists start the anaesthetic with an injection into a vein, and with the local anaesthetic cream this usually does not hurt, or not very much. Others prefer to use gas as an anaesthetic, and most will use gas if there is a particular fear of needles.

Sometimes, especially for emergencies, gas cannot be used, as there may be a risk of vomiting. Occasionally, the anaesthetist will ask parents to leave the anaesthetic room just before starting anaesthesia, as some procedures need to be done just as the anaesthetic starts. After the operation, parents can usually come back to their child as they are beginning to wake in the recovery room, so that they do not feel left alone.

Usually, pain can be controlled by use of local anaesthesia to wounds, followed by paracetamol syrup or something similar. For more major surgery other pain relief methods will be required. Discuss this with your anaesthetist at the pre-operative assessment.

What are the risks of general anaesthesia?

In modern anaesthesia, serious problems are uncommon. Risk cannot be removed completely, but modern equipment, training and drugs have made general anaesthesia a much safer procedure in recent years. Most children recover quickly and are soon back to normal after their operation and anaesthetic. Some children may suffer side effects like sickness or a sore throat. These usually last only a short time; there are medicines available to treat them, if necessary. The exact likelihood of complications depends on your child’s medical condition and on the nature of the surgery and anaesthesia your child needs. The anaesthetist can discuss this with you in detail at the pre-operative assessment.

For a child in good health having minor surgery:

• One child in 10 (like one person in a large family) might experience a headache, sore throat, sickness or dizziness.
• One child in 100 (like one person in a street) might be mildly allergic to one of the drugs that has been given.
• One child in 20,000 (like one person in a small town) might develop a serious reaction (allergy) to the anaesthetic.

Remember

• Please read this information leaflet thoroughly and ask if you are unsure about anything.
• Two days before the procedure, ensure your child eats only the foods advised in this leaflet.
• Follow the instructions for the administration of medication.
• Ensure your child drinks plenty of fluid – you may wish to use the table above to keep track of how much your child drinks.
• Ensure your child has a drink of water at 06:00am on the day of the procedure.
• Bring your child to the ATC (Addenbrooke’s Treatment Centre – Day Surgery Unit level 2) at 07:00am on the day of the procedure.
• Please call the gastroenterology nurses on 01223 348950 if you have any questions.
• Stay in the discharge lounge of the ATC during and after the procedure so that the endoscopist can find you to discuss the findings and treatment plan. If you are not available to speak to the endoscopist this can delay your child’s discharge.

Any other questions?

Feel free to write down any other questions you may have. No question is ever too minor or too simple to ask, so please ask any member of the team caring for your child if there is anything you wish to know. Your child is also encouraged to ask questions. It is important that you and your child are fully prepared for the procedure and that we try and address any and all of your worries and concerns.

If you have any problem understanding or reading any of this information, please contact any of the team below or ask your consultant for more details.

• Paediatric IBD helpline: 01223 274757 (please note that you can only leave messages on this number)
• Gastroenterology nurses: 01223 384950