Gastroenterology - Colonoscopy and Endoscopic Mucosal Resection (EMR)

Introduction 

This leaflet has been produced to give you general information about your treatment and procedure and answer any questions you may have.

It is not intended to replace the discussion between you and your Consultant, but may act as a starting point for discussion.

If after reading it you have any concerns or require further explanation, please contact the Bowel Cancer Screening (BCSP) team.

What is an Endoscopic Mucosal Resection (EMR)?

An Endoscopic Mucosal Resection, sometimes called an EMR is a different way of removing larger and flatter polyps in the large bowel.

The goal of EMR is to allow the endoscopist to obtain tissue samples or removal of polyps/lesions using the endoscope. This prevents the need for surgical treatment in the majority of patients.

The EMR procedure will be carried out by a Screening Consultant on the Endoscopy Unit at either Rochdale Infirmary or Fairfield General Hospital.

A colonoscopy test is performed, which allows the endoscopist to look at the lining of the colon (large bowel).

This is done by passing a long flexible tube with a bright light at the end, called a colonoscope (and which is about the thickness of your index finger), through your anus (back passage) and into your bowel.

Carbon dioxide or air is gently pumped in to the bowel to allow good views of the polyp during its removal.

Blue dye may be sprayed onto the polyp to help outline the edges, to assist in complete removal of the polyp.

A small amount of fluid is injected under the polyp to lift it away from the deeper muscle layers of the bowel wall. This increases the chance of a complete removal of the polyp and reduces the risk of complications.

A wire loop is then passed down the colonoscope and over the polyp, which then can be removed. Diathermy (a low electrical current) is used to remove the polyp and seal the area left behind. The polyp is collected and sent for examination under the microscope.

 

What are the possible risks?

Complications can develop during or after the procedure. Every effort is made to prevent, recognise and treat these. The risks for Endoscopic Mucosal Resection are higher for bleeding and perforation than a standard removal of polyp.

Minor Complications:

Bleeding can occur from the bottom (the anus) which has a very good blood supply and is the area where piles (haemorrhoids) are found. Inserting the scope into the bottom can cause this type of bleeding, which may be spotting on the toilet paper or drops in the toilet which should settle in a day or two.

If blue or black dye was used during the procedure, this may be seen next time you go to the toilet.

Major Complications:

Bleeding may occur in 1 patient out of every 50 patients.

It can happen at the time but can also present a few weeks after the procedure. Bleeding usually stops on its own but occasionally it may require a hospital stay, blood transfusion or further treatment.

When you have had a polyp removed, you should expect a little bleeding such as ‘spotting’ on the toilet paper or small drops in the toilet bowel. This usually subsides quickly. If bleeding begins to increase or large clots are seen and you begin to feel unwell or faint you must seek medical advice urgently.

Perforation (making a small hole in the bowel wall)

This may occur in 1 patient out of every 100 patients.

It can occur at the time of the colonoscopy but can also occur a few weeks after the test. If this happens you may need an urgent operation to repair your bowel.

If you begin to feel unwell, feel nauseous or vomit, or if your tummy becomes hard, swollen and painful and you feel hot and shivery, you must seek medical advice immediately as these types of symptoms can develop if there is a perforation.

If you have any plans to travel within 2 weeks of this procedure it is important that you discuss this with the Specialist Screening Practitioner prior to attendance, as there is a risk of late bleeding following the procedure (up to 2 weeks after).

Sedation may be given if desired to make the procedure more comfortable. Patients do not have to have sedation and some of our patients undergoing this procedure choose not to have it.
 
As a team we have no preference but insist that patients have a free choice and that sedation is used as safely as is possible.

The sedation given is usually a combination of a pain relief and a sedative. Rarely this may have an effect on the heart and lungs.

Some people can be particularly sensitive to these drugs and can breathe too shallowly and slowly. If this happened we would stop the procedure, give antidotes to the drugs to reverse their effects and take immediate steps to promote recovery.

Serious complications are rare. However, people with pre-existing medical conditions, such as heart and lung problems can have an increased risk of complications. You will be monitored throughout the procedure by appropriately trained endoscopy nurses.

Other risks:

Incomplete removal or if the polyp cannot be removed

If the polyp will not lift when injected, this means that we cannot remove it using this technique. If this happens, more samples may be taken and your care will be referred to another consultant to explore another way to remove it. We will discuss this with you before you leave the department.

Pain and discomfort

Removal of polyps may take time to be done properly and effectively, particularly if the polyp is large or in a difficult position. As the procedure carries on, gas is pumped through the camera into the bowel to keep a clear view. The accumulation of gas may lead to a feeling of bloating and discomfort. This can be quite normal for this procedure. However, if you have a concern this will be dealt with and you will be able to discuss it during the procedure.

Reaction to the drugs

This may occur and is one of the reasons that the team will carefully monitor how much sedation is given and how you respond. This means that this complication is now very rare. All staff are trained to respond to drug reactions.

What should I expect?

Bowel preparation – to allow a clear view, your bowel must be empty of waste material. You will therefore be given a bowel clearance product (laxative). The Specialist Screening Practitioner (SSP) will carefully discuss the bowel preparation instructions with you. If these instructions are not followed the test may be unsuccessful.
 
If you take iron tablets you should stop taking these for one week before the test. You must keep taking any essential prescribed tablets.

If you are taking blood thinning tablets (anticoagulants e.g. Warfarin or Clopidogrel etc.) it is important that these are stopped appropriately before your EMR procedure so that the polyp can be safely removed.

Depending on which type of blood thinning medication you are taking depends on how long you need to stop them. The SSP will discuss your medication with you and give advice about contacting your anticoagulant specialist.

If you are diabetic, please inform your diabetic nurse or the specialist who looks after your diabetes for advice.

On arrival

The SSP will introduce herself/himself to you and support you throughout your stay.

You may have some blood tests taken and your blood pressure, pulse and oxygen levels will be checked. A needle will be placed in a vein on the back of your hand so that we can provide you with sedation and pain relief.

You will be asked questions about your general health. Please bring any medication with you that you are taking.

You will be given the opportunity to ask any questions and share any worries you may have.

Prior to the procedure you will be asked to get undressed and put on a gown. Any jewellery and metal objects must be removed.
 
You will be asked to sign a consent form giving your permission for the test and procedure.

Sedation

You may be given sedation and pain relief (analgesia) for this procedure in order to help you relax. This will involve a drug being given through a needle, (usually in the back of your hand). This is NOT a general anaesthetic.

After the EMR procedure you will return to the ward where in most cases you will remain for observation until you can be safely discharged.

All patients receiving sedation will need a responsible person to accompany them home and remain with them for 24 hours following sedation. If you are the main carer for someone, please make alternative arrangements for their care.

You must not return to work, drive, drink alcohol or sign any legal documents for at least 24 hours following sedation.

For some patients, sedation is not advised. The Specialist Screening Practitioner or the Screening Consultant performing the examination will discuss this with you.

During the test

In the examination room you will be greeted by a member of the endoscopy staff who will remain with you throughout the test.
You will be made comfortable resting on your left hand side with your knees drawn up to your stomach. At this point sedation and analgesia will be given unless advised otherwise.

Oxygen may be given via a nasal cannula (small tubes placed just inside the nostrils) or a mask.

The endoscopist will then pass the colonoscope through the back passage (anus) into the bowel. Air or carbon dioxide is passed into the bowel to give a clear view of the lining. This may cause ‘wind-like’ discomfort but it should not last long. You may also get the sensation that you want to go to the toilet but as the bowel is empty there is no danger of this happening. You may pass some wind, but although you may feel embarrassed, remember it is normal. The EMR procedure will take longer than a colonoscopy.

After the test

You will be transferred to the recovery area. You may feel bloated and suffer some wind pains, but these usually settle down quickly. You will be advised when you may drink and have light refreshments. If you have had sedation, you will require someone to collect you and stay with you for 24 hours.

You will receive a copy of the colonoscopy report and your GP will also be sent a copy of the colonoscopy report. One of the SSP’s will contact you during the next working day to check that you are well after the EMR procedure.

When will I know the results?

During the EMR procedure tissue samples from the polyp will have been sent to the laboratory. You will be contacted by the Bowel Cancer Screening Programme (BCSP) team to discuss the results. The results will also be sent to your GP.

Scans might be performed at other stages in your investigation.

Consent to Treatment

Before any doctor, nurse or therapist examines or treats you, they must seek your consent or permission. In order to make a decision, you need to have information from health professionals about the treatment or investigation which is being offered to you. If you do not understand what we propose or you do not agree to it, then we cannot proceed with the procedure as you will not have consented to it.

You should always ask them more questions if you don’t understand or if you want more information.

For an Endoscopic Mucosal Resection you will be given both verbal and written information and after having time to ask questions, you will be asked to sign a consent form to show you have received enough information and you understand it. The information you receive should be about your EMR procedure and whether it carries risks as well as the benefits. What is important is that your consent is genuine or valid. That means:

• You must be able to give your consent
• You must be given enough information to enable you to make a decision
• You must be acting under your own free will and not under the strong influence of another person

General Information

The Trust has a No Smoking policy and smoking is strictly forbidden on the premises.

The use of mobile telephones is not allowed in certain areas of the hospital as they affect electronic equipment. Please ensure you switch off your phone before entering the hospital.

Do not bring any valuables with you e.g jewellery, large sums of money, cheques books or credit cards. The Northern Care Alliance NHS Foundation Trust cannot be held responsible for valuables.

Please note the unit is a mixed ward with both male and female patients.

Whilst we aim to keep your appointment time, your test may be delayed due to medical emergencies.

Telephone numbers:

Endoscopy at Fairfield General Hospital – 0161 778 2085

Endoscopy at Rochdale Infirmary – 01706 517547

Frequently Asked Questions

How long does it take?

This will be dependent on the size of the polyp and the Consultant will discuss this with you before the EMR procedure.

Will I need to take extra bowel prep?

You will be advised on the amount of bowel prep needed by the SSP and verbal and written instructions will be given.

Does it hurt?

An EMR procedure can be uncomfortable but sedation and painkillers can be offered (please see information on sedation). If you have any worries please discuss with the SSP and/or the Consultant before the EMR procedure.

Will I need to stay in overnight?

No, you will not routinely need to stay in overnight.

Will I have any pain afterwards?

You may experience some wind type pain and bloating. Simple pain relief such as Paracetamol, Ibuprofen and Aspirin can be taken to help with any discomfort.

Will I have any bleeding?

You may have some slight bleeding following the test, however this should soon stop. If bleeding begins to increase or large clots are seen and you begin to feel unwell or faint you must seek medical advice urgently.