Colonoscopy and Gastroscopy: Morning List

Advice for patients/parents

Your child will need to attend the paediatric pre-operative assessment clinic on ward F3 –level 3. This is usually on the day of your gastroenterology clinic appointment. (Your procedure cannot go ahead if you have not attended pre-operative assessment clinic. This is a drop-in clinic so you can attend it at any time during the week – Monday – Friday 8:30-16:00).

Please remember to collect your bowel prep from the outpatient pharmacy prior to leaving the hospital.

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 your child’s 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 large bowel. The large bowel/intestine is called the colon. The colon is the last part of the bowel where the final part of digestion occurs, water is absorbed and where faeces (stools) are stored until being passed out of the anus (back passage). The procedure is undertaken by an endoscopist with a narrow flexible tube like instrument that can be guided around the bowel.

Preparation

Parent and child information for bowel preparation before colonoscopy.

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 any potential risks of the procedure.

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

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 before 13.00 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’ column in the table below but must not eat any foods in the ‘foods to avoid’ column.

One day before the procedure

Ensure your child has a good breakfast, 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 is allowed:

• Water
• Clear sports drinks*
• Clear soup (no lumps)*
• Dilute 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 are included in the fluid total!

08:00

• 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.

12:00

• Dissolve the sachet of Picolax in half a cup of water and ensure your child drinks this over the next 10 to 20 minutes (use fruit squash to flavour if necessary). 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 and drink 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 it is excessive vomiting do not worry, it still works.

16:00

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

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, and you can give him/ her 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.

Your child is only allowed jelly, soup, etc, for 24 hours before their procedure i.e 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

Clear fluids (water or very dilute squash) only should be taken this morning. No food of any kind. All fluids should be stopped at 06:00. Further fluid allowances will be advised by the ward staff on arrival.

On the day of the procedure your child will be seen on the day surgery unit (level 2) in the Addenbrooke’s Treatment Centre (ATC) by the doctors, anaesthetist and nurses, to prepare your child for the procedure.

If your child’s bowel is not clear by 07:30 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 you will be asked to sign a consent form by the paediatric endoscopist. 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 cannula is 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 narrow flexible tube like instrument called a colonoscope that can be guided around the bowel. It is passed into the anus, through the colon and into the lower part of the small bowel (terminal ileum). 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 approximately round thirty minutes but times can vary considerably. If it takes longer, you should not worry.

About six biopsies will be taken. This is done by passing a small instrument called ‘forceps’ 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. This is done to help establish your child’s diagnosis.

During the procedure, parents/carers are asked to stay in the discharge lounge in the ATC and the endoscopist will come to discuss the findings and your child’s treatment plan after the procedure.

What are the benefits of the procedure?

Your doctor will 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, who will be happy to explain this to you. In most cases the procedures are done to try and help make a diagnosis i.e to work out the cause of your child’s symptoms and therefore allow better treatment. for your child.

Alternatives

The colonoscopy is the only procedure 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/type of information.

Your child’s doctor will have discussed why this procedure needs to be done, and explained why alternative tests were not suitable. If you have further questions please discuss this with your doctor.

Potential problems

Colonoscopy procedures carry a small risk of haemorrhage (bleeding) or perforation (tear) (less than one in 1,000 cases) 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 / damaged during processing to make a definite diagnosis. In certain cases it may then be necessary to repeat the procedure.

Gastroscopy

What is a gastroscopy?

A gastroscopy is also known as an upper endoscopy or OGD (Oesophago-Gastro-Duodenoscopy). You will hear both of these terms used. Please ask if you are unsure. A gastroscopy is a procedure that allows the paediatric endoscopist to look directly at the lining of the upper gut. The upper gut consists of the oesophagus (food pipe), stomach and duodenum. The duodenum (upper small bowel) is responsible for most of the digestion and absorption of nutrition.

Before the procedure

You will not need to take any additional preparation medication for the gastroscopy. The preparation taken for the colonoscopy will be sufficient for the gastroscopy.

During the gastroscopy

The procedure is undertaken with a gastroscope which is a long flexible tube (about as thick as your little finger) with a light at the end. It is passed through the mouth, into the oesophagus, the stomach and duodenum. Biopsies (samples of the lining of the gut) will be taken. The gastroscopy procedure usually takes around 15 to 20 minutes, but times can vary.

What are the benefits of the gastroscopy?

Your child’s doctor will have discussed the likely benefits of the gastroscopy, with you and your child. If you are not sure how they are likely to benefit your child’s health, then please ask one of the medical team who will be happy to explain this to you.

In most cases the procedure is done to try and help make a diagnosis i.e to work out the cause of your child’s symptoms and therefore allow for better treatment for your child.

Alternatives

The alternatives when having a gastroscopy are the same as for colonoscopy, which are discussed above

Potential problems

The potential problems when having an gastroscopy are the same as those listed above for colonoscopy, although the risks of perforation are lower (less than one in 5000 cases).

There is also a small risk that loose or wobbly teeth may be dislodged, so please inform the anaesthetist if your child has any loose or wobbly teeth.

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/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 also be given a leaflet of what you can expect in the days immediately after your child has had their procedure. Please read this 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 he/she 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® or Disprol®, will be enough, but if you need stronger painkillers, we will prescribe them before you go home.

If, when you get home, you feel that your child needs stronger pain relief, you should call your GP or ring the gastroenterology nurse specialists (on the telephone number at the end of the leaflet) for over-the-phone advice. If necessary please leave a message and we will call you. If you are concerned after 16:00 please contact A&E or out of hours service. The healthcare professional can call Addenbrooke’s main switchboard on 01223 245151 and ask them to bleep the paediatric gastroenterology nurse specialists during working hours or the paediatric registrar on call, 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 ring 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 procedure and management plan will be sent to you, your child’s GP, your referring consultant and any other health care professionals involved in your child’s care. If you do not wish for anyone involved in your child’s care to receive this information, please let one of the team know.

Training

Training doctors and other health 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. This 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 telephone: 01223 348950, 08:00 until 16:00
• Your GP and local Accident and Emergency department, 16:00 until 08:00

or;

• Addenbrooke’s Hospital main switchboard: 01223 245151 (where you should 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 generally recognise this, and do their best to keep distress down to a minimum. These days, children usually come into hospital on the same day as the operation, unless it is major, and usually do not have premeds. 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 been 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 it 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 and 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 required. The anaesthetist can discuss this with you in detail at the pre-operative visit.

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 somebody if you are unsure.
• Two days before the procedure, ensure your child eats only foods as suggested by this leaflet.
• Follow instructions for administration of medication.
• Ensure your child drinks plenty of fluid – you may wish to use the table below to keep a track of how much your child drinks.
• Ensure your child has a drink of water at 06:00 on the day of the procedure.
• Bring your child to the Addenbrookes Treatment Centre (day surgery unit level 2) at 07:00 on the day of the procedure.
• Please call the gastroenterology nurses on 01223 348950 with any questions.
• Stay in 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 silly to ask, so please ask any member of the team caring for you 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/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.

• Gastroenterology nurses: 01223 348950

If you have any questions regarding the appointment time, please contact the pathway co-ordinator on 01223 256782.