Pre-procedural Assessment, Informed Consent, and Bowel Preparation
Preparation is a procedure
Pre-procedural assessment begins with the indication: will the result change management? Document alarm features (dysphagia, weight loss, bleeding, anemia, altered bowel habit) and a focused cardiopulmonary history, including obstructive sleep apnea, prior sedation reactions, allergies, pregnancy, and antithrombotic use. Assign ASA physical status and let it drive sedation depth, monitoring, and whether anesthesia involvement is needed.
Antithrombotic management is a frequent question trap. Aspirin for secondary prevention usually continues. P2Y12 inhibitors are typically held 5-7 days before high-risk interventions such as EMR or ESD, but not before diagnostic endoscopy. Warfarin is usually stopped about 5 days before with an INR check; direct oral anticoagulants are held 1-3 days depending on renal function and bleeding risk. Bridge only for high thrombotic risk. Endocarditis prophylaxis is reserved for high-risk cardiac conditions and is not routine for GI endoscopy.
Consent is a documented conversation: indication, alternatives including no procedure, material risks (bleeding, perforation, sedation events, missed lesion), and questions. Use a surrogate for patients lacking capacity and document the emergency exception when applicable.
Bowel preparation quality is measurable. Split-dose polyethylene glycol-2 L with ascorbate or 4 L-outperforms same-day dosing. The second dose should finish 4-6 hours before the procedure. Clear liquids exclude milk, pulp, and solids. Score with the Boston Bowel Preparation Scale (0-9; adequate generally at least 2 per segment), document it, and reschedule inadequate preps because intervals and adenoma detection suffer.
Rule of thumb: a second dose taken more than 6 hours before the scope usually means a poor right-colon prep-reschedule rather than struggle.