Information for Gastroscopy
Arrive 15 minutes before examination
Please be punctual. If you will be late please contact us≪Important notice≫① Eat a light dinner by 9:00PM the day before the examination. After dinner, you may only drink wateror plain tea without milk or sugar.
② No breakfast on the examination day. Drink only water up to an hour before the examination toremove mucus in the stomach.
③ Be sure to take your regular hypertension, heart disease medications more than 2 hours before theexamination.
④ For those who take diabetes medications, consult your physician prior to the procedure.
It may be required to hold off the medication for the day.
⑤ Smoking increase the gastric juice, and it will affect the examination. please refrain from smoking⑥

Due to the effect of the medicine we use, you cannot drive a car or other vehicle or ride a motorcycle
or a bicycle on the day of the examination.

⑦

Stop taking medications that includes transamin (Tranexamic acid) and supplement one week before
the examination.

⑧

Remove all nail polish and gel nails. If not, we do not perform gastroscopy with sedatives.

⑨

We cannot perform gastroscopy for expecting mothers or those who might be pregnant. We may
limit the medicine for mothers who are breastfeeding.

⑩For women: please do not wear a one-piece≪Examination day’s schedule≫
1. Please change from your clothes to examination suit (top only) and wear slippers.
2. Before the examination you will be drinking a medicine that will clean out your stomach.
3. The doctor will do the throat anesthesia.
4. The examination takes about 15 minutes.
5. It takes about an hour including reception, preparations and payment. (When using sedatives, another60 minutes is required to recover.)≪After examination≫① Due to the local throat anesthesia, no eating, drinking, smoking for an hour after the examination.
② For those who had biopsy, no eating, drinking and smoking for 2 hours after the examination.
No alcohol and spicy or fatty foods for the day. The result of the biopsy will be explained at theoutpatient service. A biopsy will typically take 2 weeks for the result to come back.

Isinkai, Medical foundation Kaijo Building Clinic
Tokiwabashi Tower F10 2-6-4 Otemachi, Chiyoda-ku, Tokyo
2023.12 改訂

Tel : 03-6636-6050

外来胃用「胃内視鏡検査を受けられる方へ」

Consent information for Gastroscopy
Please read information, sign the consent form and bring it to the clinic on the appointment day.
<Purpose, Method>
A gastroscopy is where the doctor uses an instrument called an endoscope to look at the inside lining ofyour esophagus (food pipe), stomach and duodenum (first part of the small intestine).
An endoscope is a long, thin, flexible tube with a small camera and light attached which allows doctors tosee the inside of your gut on a video screen. Sample biopsy may be performed if we find any polyp, ulcer
or tumor. We will apply a local anesthesia to your throat. If requested or as necessary, we will use
sedatives by dripping infusion. We may not be able to follow your requested method depending on yourcondition and medications.
<Notes>Unintended side effects (such as: perforations, bleedings) may occur due to the biopsy. It happens toabout 1 in 14406 people. About 1 in 866591 such cases lead to death. Throat anesthesia and sedatives
may cause dyspnea (shortness of breath) and other side effects. If any accidental events happen during
the procedure, we will provide the best treatment but may require hospitalization or emergency
operation.
Please inform the medical staff if the statements below apply to you before the procedure.
① Unwell after given local anesthesia or allergy to local anesthesia at dentist. (We use Xylocaine as
local anesthesia to your throat).
② Currently under medical treatment or has history of hospitalization.
③ Taking antithrombotic medicine (anticoagulant, antiplatelet agent). Please refer to the information
for “For those who take antithrombotic”.
If ② or ③ applies, follow the instructions given by our nurse or doctor on how to take yourmedication when you make the appointment. For those who are taking antithrombotic, you must consult
your physician prior to the examination on your medication.
We may not perform biopsy by the decision of the examiner or by your request.
The sedatives may cause drowsiness, lowered vision, and amnesia. Do not drive and cycle for the day. Do
not make any critical decision on the day.
※Please write it with pen
I acknowledge the needs, contents and risks of the gastroscopy.
Please circle your choice.
I ( consent do not consent ) to perform this examination.
Name(Signature)_______

Date of consent(If substitution, please state relationship with patienty/m/d)

Address
contact number
If patient lack capacity to provide consent, consent must be obtained from substitute decision maker(spouse, guardian, parental authority) and sign the consent form.

Kaijo Building Clinic
TOKYO TORCH Tokiwabashi Tower 10F 6-4,Otemachi 2-chome,Chiyoda-ku, Tokyo Tel : 03-6636-6111
2023.12 改訂 二次検胃同意書

For those who take antithrombotic medicine
Managing of antithrombotic medicine in endoscopy

In principle, we will perform endoscopy for those who are taking
antithrombotic medicine.

Depend on the type of medicine you are taking, we may not performthe biopsy.
You must consult your physician prior to the procedure. Yourphysician will decide if you can continue taking your antithrombotic
medicine or not.
Kaijo Building Clinic, Director

Lists of medicine might affect endoscopy on reverse side.

2023.12 改訂 二次検用 「抗血栓薬内服中の方へ」

内視鏡検査に影響のあるお薬一覧 Affects endoscopy drug List

2024.1※休薬の可否については、必ず主治医にご確認ください。You have to check with your doctor about whether or not you can take medication.

成分名Ingredient name

製品名
product name後発医薬品（ジェネリック）・同成分薬
Generic drug・Same component drug

ｱｽﾋﾟﾘﾝ
aspirin

バイアスピリン
Bayaspirin

ｱｽﾋﾟﾘﾝ
Aspirinｱｽﾋﾟﾘﾝ・ﾀﾞｲｱﾙﾐﾈｰﾄ配合
aspirin・dialuminate

バファリン
Bufferin

ｱｽﾌｧﾈｰﾄ , ﾆﾄｷﾞｽ , ﾊﾞｯｻﾐﾝ , ﾌｧﾓﾀｰ
Asphanate , Nitogis , Bassamin , Famoter

ｱｽﾋﾟﾘﾝ・ﾎﾞﾉﾌﾟﾗｻﾞﾝﾌﾏﾙ酸塩配合
aspirin・vonoprazan humarate
combined drug

キャブピリン配合錠
Cabpirin

ｱｽﾋﾟﾘﾝ・ﾗﾝｿﾌﾟﾗｿﾞｰﾙ配合
aspirin・lansoprazole combined drug

タケルダ配合錠
Takeldaｱﾋﾟｷｻﾊﾞﾝapixaban

エリキュースEliquisｲｺｻﾍﾟﾝﾄ酸ｴﾁﾙ
ethyl icosapentate

エパデールS Epadel S
エパデール Epadel
エパデールEM Epadel EM

ｴﾄﾞｷｻﾊﾞﾝﾄｼﾙ酸塩水和物
edoxaban tosilate hydlate

リクシアナ
Lixiana

ｵﾒｶﾞｰ3脂肪酸ｴﾁﾙ
Anti-hyperlipidemic Agents

ロトリガ
Lotriga

ｵﾒｶﾞｰ3脂肪酸ｴﾁﾙ
Anti-hyperlipidemic Agents

ｸﾛﾋﾟﾄﾞｸﾞﾚﾙ硫酸塩
clopidogrel sulfate

プラビックスPlavixｸﾛﾋﾟドｸﾞﾚﾙ
Clopidogrel

ｸﾛﾋﾟﾄﾞｸﾞﾚﾙ硫酸塩・ｱｽﾋﾟﾘﾝ配合
clopidogrel sulfate・aspirin

コンプラビン配合錠
Complavin

ﾛﾚｱｽ
LoreAceｻﾙﾎﾟｸﾞﾚﾗｰﾄ塩酸塩sarpogrelate hydrochloride

アンプラーグ
Ａｎｐｌａｇｻﾙﾎﾟｸﾞﾚﾗｰﾄ塩酸塩
Sarpogrelate hydrochloride

ｼﾞﾋﾟﾘﾀﾞﾓｰﾙ
dipyridamole

ペルサンチン
Persantin

ｼﾞﾋﾟﾘﾀﾞﾓｰﾙ（＋散）Dipyridamole

ｼﾞﾗｾﾞﾌﾟ塩酸塩水和物
dilazep dihydrochloride hydrate

コメリアン
Comelian

ｼﾞﾗｾﾞﾌﾟ塩酸塩
Dilazep dihydrochloride

ｼﾛｽﾀｿﾞｰﾙ
cilostazol

プレタール
Pletaal

ｼﾛｽﾀｿﾞｰﾙ(＋錠,OD錠,内服ｾﾞﾘｰ）
Cilostazol

ﾀﾞﾋﾞｶﾞﾄﾗﾝｴﾃｷｼﾗｰﾄﾒﾀﾝｽﾙﾎﾝ酸塩
dabigatran etexilate methanesulfonate

プラザキサ
Prazaxa

ﾁｶｸﾞﾚﾛﾙ
ticagrelor

ブリリンタ
Brilinta

ﾁｸﾛﾋﾟｼﾞﾝ塩酸塩
ticlopidine hydrochloride

パナルジン
Panaldine

ﾌﾟﾗｽｸﾞﾚﾙ塩酸塩
prasugrel hydrochloride

エフィエントEfientﾍﾞﾗﾌﾟﾛｽﾄﾅﾄﾘｳﾑberaprost sodium

ケアロードLA Careload LAドルナーDorner
プロサイリン Procylin
ベラサスLA Berasus LA

ﾘﾊﾞｰﾛｷｻﾊﾞﾝ
rivaroxaban

イグザレルトXareltoﾘﾏﾌﾟﾛｽﾄｱﾙﾌｧﾃﾞｸｽ
limaprost alfadex

オパルモン
Opalmonﾘﾏﾌﾟﾛｽﾄｱﾙﾌｧﾃﾞｸｽ
Limaprost alfadex

ﾜﾙﾌｧﾘﾝｶﾘｳﾑ
warfarin potassium

ワーファリン
Warfarin

ﾜﾙﾌｧﾘﾝK（＋細粒）
Warfarin K

ｲｺｻﾍﾟﾝﾄ酸ｴﾁﾙ
Ethyl icosapentate

ﾁｸﾛﾋﾟｼﾞﾝ塩酸塩
Ticlopidine hydrochloride

ﾍﾞﾗﾌﾟﾛｽﾄNa , ﾍﾞﾗﾌﾟﾛｽﾄﾅﾄﾘｳﾑ
Beraprost Na , Beraprost sodium※上記は、「今日の治療薬2024年版」を参照し作成しております。
The above reference and create “Today's remedy 2024 edition”.
記載されていない後発医薬品（ジェネリック）が存在する場合もありますので、ご了承願います。
Please note, in some cases Generic drugs not listed.
※院内採用薬品は青字で表記しております。ご不明な場合はお問い合わせください。
Drugs used in hospitals are shown in blue. If you are unsure, please contact us.

医療法人財団医親会 海上ビル診療所

KAIJO BLDG. CLINIC