An anticoagulant medicine reduces the risk of blood clots forming in your blood vessels, and treats existing blood clots, by making your blood take longer to clot. They are sometimes called “blood thinners”. 

There are several reasons. You may have already had a blood clot, for example a deep vein thrombosis, or you may have a condition that makes it more likely that a clot will develop in the future, for example atrial fibrillation or a replacement heart valve.

There are many different types of anticoagulants available. The type prescribed for you will be based on your individual clinical requirements.

You clinician will advise how long you need to take warfarin. Some people only need a short course of treatment, for example up to 3 months. Others will need to take warfarin for the rest of their life, like those with a mechanical heart valve. 

There are 4 strengths of warfarin tablets available in the UK:

• 500 micrograms (0.5mg) (white).
• 1mg (brown).
• 3mg (blue).
• 5mg (pink).

If you know the strength of the tablets you have you can use any combination to make up the right dose. Please speak to your GP or warfarin clinic if you are not sure how to make up a dose.

Swallow the tablets with a full glass of water. Take the tablets at the same time each day, ideally in the evening (around 18:00). This allows the warfarin clinic or GP to contact you before you take that day’s dose if your INR result is high.

If this is inconvenient, warfarin can be taken another time, as long as it is roughly the same time each day.

If you forget your dose you can take it up to 6 hours late (for example if you usually take it at 18:00 and forget, you can take it by midnight). If your dose is more than 6 hours late, make a note and tell the clinic/GP as soon as you can the next day.

If you have difficulty remembering whether you have taken tablets, or are taking different doses on different days, you can use a calendar to record that you have taken your tablets. Put a line through each date on the calendar as soon as you have taken the tablets.

Always make sure that you have at least a week’s supply of warfarin tablets so you do not run out. We advise you keep a supply of tablets of different strength in case your dose is altered. When your warfarin prescription is ordered or collected from a pharmacy, they may ask for details of your INR and warfarin dose.

Unlike many other tablets there is not standard dose of warfarin. Instead, the dose needed depends on the effect it has on slowing of the clotting in your blood.

This is measured in the laboratory by a blood test called the INR (International Normalised Ratio). The INR result for someone not taking warfarin is around 1. Your target INR result will have been set by the clinician who started you on warfarin.

A common target INR is 2.5 (range 2.0-3.0), which means that your blood will take just over twice as long as normal to clot.

Many factors can affect your INR test results, including your general health, diet, and any other medications that you take.

Your INR results will vary and fluctuate naturally, even if your warfarin dose and lifestyle don’t change. The aim is to keep your blood test within 0.5 of your target INR. For example, if your target is 2.5, your INR result should ideally be within the range 2.0-3.0.

• If your INR is too high, you are at higher risk of bleeding.
• If your INR is too low, you are at a higher risk of blood clotting.
• For all INR results you will be contacted by the clinic/GP for review.

In specific situations, some patients may need additional blood thinning injections into the abdomen (tummy) for a short time whilst their INR is low. This covers the period of higher clotting risk.

At the start of treatments, you will need INR tests more frequently to find the right warfarin dose for you. Once your dose has been stabilised your tests will become less frequent. The maximum time between blood tests is up to 12 weeks. It is not possible to tell you at the beginning of treatment how frequently you will need INR tests, but your clinic or GP will guide you.

• The first time you need an INR blood test, an appointment will be made for you by your GP or hospital (whoever arranged for you to start warfarin). It is important you know when your next blood test is due.
• After the first INR blood test, you should be contacted by your clinic/GP. If you have not heard from them by the end of the following day with the result, or are unsure of your warfarin dose, please contact your GP. 

Warfarin can be affected by many medicines, including antibiotics, cholesterol medication, epilepsy medicines, some painkillers, and some heart tablets.

Paracetamol is safe to take but other painkillers should be checked with a doctor or pharmacist. Do not take aspirin, things containing aspirin, or anti-inflammatory painkillers (like ibuprofen or naproxen) unless a healthcare professional who knows you take warfarin advises you to.

Before starting new prescribed medicine, or buying medicine (including herbal remedies and vitamins), please remind the doctor or pharmacist that you take warfarin. If your medicines have changed (especially antibiotics), please inform your warfarin clinic as an INR test may be needed sooner.

It is recommended to drink no more than 14 units of alcohol a week, which should be spread evenly across the week. This is a maximum of 2 units of alcohol a day, as in no more than 1 pint of beer or 1 medium glass of wine per day.

It is dangerous to ‘binge drink’ while taking warfarin as it can lead to a high INR result and an increased risk of bleeding.

• Normal strength lager/beer/cider (3-4%): 1 pint = 2 units.
• Wine (11-14%): 175ml glass (standard/medium) = 2 units.
• Spirits (around 40%): single measure (25ml) = 1 unit.

Vitamin K is important for a healthy balanced diet, but it can affect your INR. You do not have to cut these foods completely out from your diet, but increasing your intake of foods rich in vitamin K can lower your INR. These include:

• Green leafy vegetables like cabbage, kale, spinach, broccoli, and lettuce.
• Liver.
• Cereals containing wheat bran and oats.
• Plant derived oils.

Try to eat similar amounts of these foods each week. Avoid sudden changes such as crash diets. Speak to your clinician or warfarin clinic if you want to change your diet whilst taking warfarin.

You should not consume cranberry/grapefruit/pomegranate juice or products containing these whilst taking warfarin as they can put you at higher risk of bleeding. 

Where possible, avoid risks from falls and injury as you may bleed more from these. Do not take part in contact sports like rugby, and try to minimise the risk of harm from manual work injury.

Try to protect yourself from injury where able, for example consider using a soft toothbrush, an electric razor, and gloves and long-sleeved clothes when gardening.

Most patients do not have side effects whilst taking warfarin. However, a small number of patients may develop 1 of the following: rash, hair thinning, diarrhoea, nausea, or vomiting. 

You should contact your clinician or warfarin clinic if you think you are having any of these side effects from your warfarin therapy.

It is common to bruise more easily whilst taking warfarin. Cuts may also take longer to stop bleeding. Nosebleeds or bleeding from cuts usually stops after applying pressure for around 5 minutes.

If you develop any of the following, you should seek medical advice and have your INR checked immediately:

• Prolonged nosebleeds.
• Bleeding gums.
• Blood in vomit (may look like ground coffee).
• Passing blood in your urine, or black or red stools (poo).
• Headache that is unusually severe, or doesn’t go away.
• Unexplained, severe bruising.
• Feeling exceptionally tired, dizzy, pale, or weak.
• Unexplained swelling.
• For women, increased bleeding during periods (or other vaginal bleeding).

Seek urgent medical attention (phone 999) if you:

• Are unable to stop bleeding.
• Suffer a significant blow to the head.
• Are involved in a major trauma (accident).

If your warfarin control is within your target range and you have unexplained bruising or bleeding, the symptoms should be investigated. If your INR is higher than expected, you may be advised to miss warfarin doses and/or receive some vitamin K to reverse the effects of warfarin.

The most significant risk from taking warfarin is bleeding. It is essential you take the correct dose, and go regularly for INR tests as advised.

You can have surgery whilst taking warfarin, but the dose may need to be adjusted. Your clinician or the pre-operative assessment clinic (POAC) might advise you to stop your warfarin for several days before an operation or procedure, or they might require your INR to be below a certain level.

Please follow their advice and let your warfarin clinic or GP know that you have surgery scheduled so your warfarin dose can be adjusted in advance if needed.

You must tell your surgeon that you take warfarin. They will need to know your warfarin dose, target INR, and recent INR results.

Never assume that the surgeon knows or remembers you are taking warfarin.

If your operation or procedure is cancelled, please contact your clinician or the POAC for advice on restarting warfarin.

Most dental treatment can go ahead without changing your warfarin dose. However, make sure your dentist knows you take warfarin - your INR may need to be checked a few days before a procedure.

Periods

Women may have heavier periods whilst they are taking warfarin and may wish to discuss this with their GP. You should be provided with an information leaflet with more detail about what is considered “abnormal” bleeding whilst taking anticoagulants.

Pregnancy

Women who take warfarin should use reliable contraceptives and discuss plans for future pregnancy with their doctor before trying to conceive. Women who think they are pregnant whilst taking warfarin should take a pregnancy test as soon as possible and if this is positive, make an urgent appointment with a doctor to discuss the next steps.

Breastfeeding

Warfarin is the best oral anticoagulant for breastfeeding women.

If your warfarin management is well controlled and stable, there is no problem with you going away. Please inform your warfarin clinic or GP if you have a holiday coming up or are leaving home for a long time.

For short periods you won’t need to have an INR test while you are away, and you can carry on as normal. If you develop any complications like unexplained bleeding or bruising, or become very unwell you must seek medical help locally.

If you are going away for a longer period (for example over a month) you may need an INR test while you are away. Contact your warfarin clinic or GP for advice before you go away.

• In the UK, you may be able to register as a temporary patient at a GP surgery.
• If you are abroad, you should go to a local medical centre or hospital.

Remember that if you require medical attention or need to have blood tests abroad it may be very expensive unless you have appropriate insurance. Please make sure you have purchased travel insurance before your holiday.

It is also important to try to avoid significant changes in your diet or alcohol consumption while you are away as this could affect your INR and put you at risk.

• The INR test is ideally taking in the morning usually at your GP practice, or sometimes at home. The INR test results will come to the warfarin clinic who will advise you on your ongoing dose and next test date.
• After the first blood test (and subsequent tests) you will be sent a yellow slip in the post with information on how much warfarin to take, and when you should have your next INR test in the post.
• It is your responsibility to book in the next INR test with your GP surgery. If you struggle to book the test on the recommended date, please contact the warfarin clinic.
• There is space in the bottom section of the slip to write important information about your health that could affect the warfarin. For example changes to medication, recent illness, or missed dose. Please complete this and bring it to your next INR test. Part of this section is removed to send with the blood sample and identify you. Be careful to avoid ripping the tear-off slip.
• Once your INR test has been reviewed by the clinic, a new yellow slip will be posted to you. Your GP practice will also receive an electronic copy of your warfarin dosing instructions.
• We will contact you by phone if your INR is very low or high, or we need to speak to you. It is important we have up to date contact phone number(s) so we can get information to you or your family/carer quickly.
• If you care for someone who takes warfarin, but you know that they would not be able to receive/understand a phone call from us, please let us know how we can contact you instead.
• We can also send the INR test result and dosing information to you/your carer by email.

How to get help

• We are available Monday to Friday, 10:00 to 17:00 on 0117 414 8405
• If possible, please make any calls before 16:00. If your call is not answered, leave a message and you will usually be called back the same day.
• Please do not routinely contact the helpdesk to find out your result and dose unless there is a very urgent need. For example a result not received before going on holiday, result needed before dental/surgical procedure, or more than 4 working days since your INR blood test. Your GP also has the results.

• The first time you need an INR blood test, an appointment will be made for you by the GP or hospital (whoever arrange for you to start warfarin). If is important that you know when your next blood test is due.
• The INR blood test is ideally taken in the morning, usually at your GP practice, but sometimes at home or at the BRI blood room. The INR test results will come to the BRI warfarin clinic, who will contact you to advise you on your ongoing warfarin dose and the next test date.
• We will contact you by phone if your INR is very low or high, or if we need to speak to you. It is important we have up to date contact phone number(s) so we can get information to you or your family/carer quickly.
• You can choose to receive letters or text messages with your dosing information for your records .Your GP practice also has your INR result and will receive an electronic copy of your warfarin dosing instructions.
• If you need advice or have not heard from us/received a letter or text within 3 working days of your INR test, please contact us on: 0117 342 3874
• We are available Monday to Friday, 09:00 to 17:00. If we do not answer the phone, please leave a message and we will get back to you as soon as possible, usually the same day.
• It is your responsibility to book your INR tests with your GP practice. If you struggle to book the test on the recommended date, please contact the warfarin clinic.
• If you care for someone who takes warfarin, but you know that they would not be able to receive/understand a phone call from us, please let us know how we can contact you instead.

British Committee for Standards in Haematology (BSCH) (2011) Guidelines on oral anticoagulation with warfarin - 4th edition. British Journal of Haematology 154 (3), pp. 311-324. . Available from: Oral Anticoagulation with Warfarin - 4th Edition) [Accessed December 2024].

Joint Formulary Committee. British National Formulary [online] London: BMJ Publishing Group Ltd and Royal Pharmaceutical Society. Available from: BNF (British National Formulary) | NICE [Accessed May 2024].

NPSA alert 18. Actions that can make anticoagulant therapy safer. 2007. Available from:  Actions that can make anticoagulant therapy safer: Alert and other information [Accessed December 2024].

Poller L et al (1998) Multicentre randomised study of computerised anticoagulant dosage. European Concerted Action on anticoagulation Lancet 352 (9139),15059.

Email: HaematologyMMR@nbt.nhs.uk

Clinical Nurse Specialist
07545 421893
If no answer, please leave a message. We aim to respond within two working days. 

You have had a cystoscopy (where a special telescope is passed into your bladder), an ultrasound scan, or an X-ray which shows that you have a tumour in your bladder.

Bladder cancers grow and look like warts or mushrooms on the lining of the bladder. As they develop, they can put down deeper roots into the muscle wall of the bladder (this is called a muscle invasive tumour). Most bladder cancers are small. They are called superficial (or non-muscle invasive) bladder cancers and are confined to the inner lining of the bladder only.

Benefits 

By removing the tumour, we can analyse the samples under a microscope to find out more about whether your condition is cancerous, assess what type of cancer this is and how far it has gone into the bladder wall. This information will help us plan any further treatment you may need.

Risks

Common (almost all patients will experience):

• Need for a period of catheterisation (a catheter is a tube placed into the bladder, to drain your urine) post-operatively.
• Mild burning or bleeding for a short time after the operation. It is normal for this to happen after your operation and will ease over 10-14 days.

Less common (between 1 in 10 and 1 in 50) patients will experience:

• Infection of your bladder requiring antibiotic treatment.
• Recurrence of the tumour (it grows back after removal) and/or incomplete removal.

Rarely (between 1 in 50 and 1 in 250) patients will experience:

• Delayed or ongoing bleeding requiring further surgery or readmission to hospital.
• Damage to the ureters (pipes draining your kidneys).
• Injury to your urethra (waterpipe) causing delayed scarring and a stricture (narrowing).
• Perforation (a hole) in your bladder requiring a catheter for a prolonged period or open surgical repair.
• Anaesthetic or cardiovascular problems possibly requiring intensive care (including chest infection, pulmonary embolus (lung clot), deep vein thrombosis (leg clot), heart attack and death). Your anaesthetist can estimate your individual risk.

The surgeon will discuss with you how likely any of these are and how they are treated, before your operation.

What are the risks of a general anaesthetic?

Straight afterwards you may feel tired, dizzy, or weak. You must have someone to collect you and stay with you for the first 24 hours. 

During the first 24 hours you should not:

• Drive or operate any motorised vehicle or electrical equipment.
• Sign any legal documents or make important decisions.
• Drink alcohol.

You may feel weak or dizzy at times during the first 7 – 10 days. If this happens, sit down until the feeling passes. 

You may also have the ‘post-operative blues’ and feel a little depressed. If any of these symptoms do not go away, please contact your GP for help and advice.

Removing the tumour is the only reliable way to find out what type of tumour you have. If you do not have the operation and the tumour is a superficial (non muscle invasive) bladder cancer (just on the surface of your bladder), there is a risk that it will change into an invasive cancer or grow bigger if not removed.

If the tumour is a muscle invasive bladder cancer and it is not removed, there is a risk that it will grow deeper into the tissues of your bladder and the cancer may spread to other parts of your body, which could affect your lifespan. In some cases, chemotherapy, immunotherapy, radiotherapy, or cystectomy may be alternative options.

Chemotherapy or immunotherapy – where medicines are instilled into your bladder (for early cancer) or given intravenously (for more advanced cancer). This is not usually performed without samples having been taken from the bladder.

Radiotherapy – where radio waves are aimed at your bladder (usually for more advanced cancers). This is not usually done without samples having been taken from the bladder.

Cystectomy – a major operation to remove the bladder, this is usually an option for more advanced tumours and is not usually done without samples being taken from the bladder first.

If you cannot have a general or spinal anaesthetic, there is an option to perform this operation under a local anaesthetic with a laser (Trans Urethral Laser Ablation – TULA), however, this is not the preferred option, as we do not get as much information about your cancer. TULA is therefore only offered in specific circumstances such as if you are very high risk for complications from a general or spinal anaesthetic.

A request form is completed by the doctor you see in clinic and sent to the waiting list team. 

The request is then processed and a date for pre-op assessment (if you do not have it on the same day as your outpatient appointment) and surgery will be sent to you through the post or by phone. 

Pre-op assessment clinic

At your pre-op assessment, a nurse will take your medical history, explain the type of anaesthetic you will have (usually a general anaesthetic), and what to expect after surgery. They will also answer any questions you may have. 

Please bring details of any medication you are taking or the medicines themselves. Also let the nurse know if you are allergic to any medicines, tablets, or plasters. 

You will have some screening tests. These may include checking. your blood pressure, taking a blood sample or having an electrocardiogram (ECG) to check your heart. 

The nurse will confirm that you are medically fit for your operation as a day case procedure, or if not fit and able for a day case, they explain about staying in hospital overnight. Day case is the standard at North Bristol NHS Trust.

The letter from the hospital will provide full details, but it usually asks you to report to Medirooms, Gate 21, Level 3, Brunel Building, Southmead Hospital.

If you have been given a consent form, please bring it with you. 

What happens during the operation?

• We will usually give you a general anaesthetic (where you are put to sleep) but may also carry out the procedure under spinal anaesthetic (where you have an injection in your back to numb you from the waist downwards).
• Once you are anaesthetised, you will usually have an injection of antibiotics to try to prevent any infections afterwards.
• Your surgeon will then put a telescopic instrument called a cystoscope into your urethra (the tube through which you pass urine) and up into your bladder. The cystoscope is about the thickness of a pencil or a pen and has a tiny video camera on one end, so your surgeon can view an image of your urinary system on a television screen. If your urethra is too narrow, they will gently insert small instruments called dilators to gradually widen the opening.
• Your surgeon will inject sterile salt water (saline) through the cystoscope to help expand your bladder and allow them to get a clear view of the tumour. They will pass small instruments through the cystoscope to collect a tissue sample (biopsy) from inside your bladder. This sample will be sent to the laboratory to be examined.
• Your surgeon will then cut away either part, or all of the tumour. The tumour will be sent to the laboratory for further tests and analysis. Because we do not need to make any cuts on the outside of your body during this procedure, you will not have any visible wounds or stitches.

How long does the operation take? 

The procedure takes about 45 minutes to 1 hour and 15 minutes, depending on the size of your tumour and where it is.

As you had a general or spinal anaesthetic you will go to the recovery area in the theatre department for at least four hours because you will feel drowsy and need time to recover (general) or your legs will still be numb for a few hours (spinal).

You will need a relative, friend, or carer who can escort you home and stay with you for the first 24 hours after your procedure. Please let them know they may have to wait for you if you are not ready to leave.

You may have a urinary catheter left in your bladder after your operation. This is a flexible tube that drains your urine into a bag outside your body. The catheter may also be used to flush out your bladder and wash away any blood clots after surgery (called irrigation). This means you will have a bag of salt solution connected to the catheter which will flow into your bladder. This irrigation will be stopped once your urine runs clear.

The other reason for having a catheter in after this procedure is that you may be offered a dose of intravesical chemotherapy (Mitomycin C) after the operation – Mitomycin C is put into the bladder for an hour using your catheter. This has been proven to help prevent tumours from growing back. Occasionally there may be reasons why this is not suitable, and your surgeon will discuss this with you before the operation.

You may need to have the catheter in anywhere from 2-10 days, depending on what happens during the operation. For most people, this is 2-5 days. Before you leave hospital, you will be given a date to return to hospital for the removal of your catheter (Trial Without Catheter – TWOC). Our nurses will explain how to care for the catheter, and when and where to return to have it removed.

Sometimes we are able to put you on a pathway where you are able to remove the catheter yourself at home (self TWOC). If you are suitable for this, you will be given details of this after the operation.

In most situations, this will be day case surgery and you will be able to go home on the same day, once you have fully recovered. 

Please ask your surgical team for a fit note (sick note) if required.

You may want to go to the loo more often for a while after the catheter has been removed. You may also find it quite sore or painful the first few times that you pass urine. This is normal. It may take several weeks for these symptoms to settle. 

You may pass some blood or small clots in your urine for 10-14 days after your operation. This is normal. Drink plenty of fluids (not alcoholic) to help wash away the blood and ease any soreness. 

We advise you to:

• Speak to your doctor about how much time you will need off work after your operation. This will depend on how quickly you recover and the type of work you do. You usually need to take about 2 weeks off. If your job involves lifting or heavy work, you may need to be away from work for 3-4 weeks.
• Start gentle exercises about a week after your surgery. Please do not do anything too energetic for 1 month, such as playing contact sports like rugby.
• Avoid driving until you feel comfortable and can do an emergency stop. Please check with your insurance provider before starting to drive again.

We may give you antibiotics to prevent you from developing an infection after your operation. Please make sure you take the whole course.

If samples were sent away as part of the procedure, you will be informed of the results 2-3 weeks after the surgery, usually by an appointment with one of our Cancer Nurse Specialists. 

If you have a catheter, we will arrange an appointment for you to have it removed, anytime from 2-10 days after the procedure. This appointment is usually at Urology Outpatients, Gate 36, Level 1, pink zone, in the Brunel Building, Southmead Hospital.

Please do not bring in valuables, jewellery or large sums of money. If this is unavoidable, please ask a relative to take them home for you. The hospital cannot accept liability for the loss of personal items.

For general queries or concerns after your operation, please contact the hospital on: 

Gate 36 (Urology Outpatients): 0117 414 0740 

Urology Cancer Nurse Specialists: 0117 414 0512

It is important to tell the doctor or nurse about any tablets or injections you are taking before you attend for your bone marrow test, as they may have to be stopped for a short while before having the test. This is especially important for medications that thin your blood, for example warfarin, apixaban, rivaroxaban, edoxaban, dabigatran or heparin/enoxaparin. We also need to know about any allergies you may have.

The procedure takes about 15-30 minutes, and you should feel well enough to go home after a short rest. 

You should allow around an hour for this appointment. There are no special preparations, but it is sensible to have something to eat and drink beforehand or you may feel light- headed during the procedure. We recommended you ask a family member or friend to come with you and take you home afterwards. We advise you don’t drive home if possible. 

You will be asked to sign a consent form and will have the opportunity to ask questions beforehand. The procedure is done under local anaesthetic by a doctor or clinical nurse specialist. In some cases, nitrous oxide (gas and air), an inhaled painkiller, can be used. It is safe and it wears off quickly. Please ask if you would like to have this. 

Please ask us if you would like more information about pain relief during the procedure. You can phone us on the number in the how to contact us box.

The bone marrow exists throughout the body, in the cavities of the bones. The most common place to take a bone marrow is at the back of the pelvis (if you place your hands on your hips, the thumbs will be over the place where the bone marrow is taken). Marrow can also be taken from the breast bone (sternum) but this is unusual.

You will be asked to lie on your side with your knees tucked up. The doctor/nurse will first examine you carefully to choose the most suitable site. Then the skin will be cleaned using an antiseptic fluid. Local anaesthetic will be used to numb the skin and the surface of the bone.

The needle is then pushed through the skin and the outer surface of the bone until it reaches the bone marrow. You may feel some pressure as the needle is pushed into the bone. A syringe is then attached to the needle and a small sample of bone marrow is sucked out into the syringe. This produces an uncomfortable sensation, which may shoot down your leg. This only lasts a few seconds. The needle is then withdrawn, and pressure applied to prevent bruising.

If you need to have a trephine sample as well as an aspirate this will be done under the same local anaesthetic. You will again feel pressure and pushing as a new needle is rotated into the bone. You may feel a dull ache as the core is removed. Again, this might travel down your leg.

Once the procedure is complete, pressure is applied to the area to stop any bleeding and a dressing is applied to the area.

You will be asked to lie down and rest for a short time after the procedure to make sure there is no excessive bleeding. 

You may have some discomfort and bruising over the test site for a few days which can be eased with paracetamol. The dressing should be left in place for at least 24 hours while a scab forms. You are advised to keep the site covered for a further 2 or 3 days.

As with all medical procedures, there is an extremely rare chance that a problem may occur. These can include:

• Bleeding: in a small number of cases there is some bleeding from the biopsy site. This usually stops by itself. Very rarely the bleeding is more severe and may require a blood transfusion. If you are taking blood thinners, please inform us before attending for your bone marrow.
• Infection: there is a very small risk that the small wound may become infected. Please contact us if you are concerned.
• Allergy: rarely you may have an allergic reaction to the anaesthetic, cleaning solution, or dressing.
• Damage to nearby structures: rarely the needle damages other nearby structures (for example nerves and muscles).
• Insufficient sample: occasionally, it may be necessary to repeat the procedure if the sample is not of suitable quality for testing in the laboratory.
• Pain: pain should be well controlled after the procedure with simple paracetamol. Please refer to the Post Bone Marrow information if this is not the case.

It would be difficult for your doctor to make the right diagnosis and decide on the correct treatment for your problem.

The laboratory tests can take two to three weeks to complete, depending on the information required. Your doctor will discuss with you when and how you will receive your results.

You will be asked to attend the Medical Day Care Unit at Gate 5b (Room 28) Southmead Hospital for your test.

Medical day care schedulers

0117 414 3206 
0117 414 3205
09:00 - 16:00

Clinical Nurse Specialist 

07545 421 893 
This number has an out of hours answer machine. We will get back to you within one working day.

You can be referred at any stage of your baby’s admission to NICU.

If you would like to be referred, please ask any member of your hospital care team such as your baby’s nurse.

• You will be contacted to arrange a time to meet, either in hospital or via phone/video call if you prefer.
• The psychologist can see you on your own or with your partner or other family members. It is your choice.
• If you require an interpreter, please let us know.
• The first meeting is an opportunity to talk about what is most challenging for you. We can think together about what might support you while your baby is in NICU.
• There may be a small wait for appointments.
• Sometimes we have trainees working in the team, all of whom are supervised. We will check first to see if you are comfortable meeting with a trainee.
• Sometimes, it may be enough to meet with a psychologist once or twice, other times you may wish to meet more regularly.

Any information you share with the psychologist is confidential. This means it will not be shared without your permission unless there is concern about risk of harm to you, your child, or others.

Parents sometimes find it useful to share information with the clinical team to help them understand the best way to communicate with you, and care for your baby.

Notes from your conversations are documented in your hospital record, this is separate to your baby’s medical notes. A brief record of contact is made in your baby’s medical notes to the clinical team are aware the psychologist has met you.

The decision to use the psychology service is entirely up to you. If you decide not to, it will not affect your baby’s care.

This page on the North Bristol NHS Trust website has links to many organisations who provide support and information to parents of babies in the neonatal unit: NICU Useful Links | North Bristol NHS Trust

South West Neonatal Network 

The South West Neonatal Network have put together virtual tours of the neonatal units in the area as well as the ambulances that transfer neonatal babies in the region. You may find this useful to look at before your first visit: SW Neonatal Units — South West Neonatal Network

You can contact our team Monday to Friday (excluding bank holidays) 09:00 to 16:00 on 0117 414 6818. 

You can ask any of your baby’s care team to contact us on your behalf and they will be happy to help. 

We hope you are pleased with the psychological service you receive.  

Our service is continually developing and reviewing our practice so we can ensure families receive the best support possible. 

When your support from our service comes to an end, you may be asked if you are happy to be contacted for your feedback and views on how the services can be improved. 

If you have concerns about the service you receive from the psychologist, please discuss them with the psychologist or another member of the NICU team. 

If this does not address your concerns, please contact the Patient Experience Team on 0117 414 4569 or email pals@nbt.nhs.uk. 

The intragastric balloon is a minimally invasive procedure where a soft deflated balloon is temporarily placed in the stomach. This is done using a thin tube called an endoscope through the mouth and gullet (oesophagus) under a general anaesthetic (you will be asleep).

Once the balloon is in the top of the stomach it is inflated with blue stained liquid (sodium chloride). This fills part of the stomach and makes you feel full.

The aim is to help change your eating pattern, reduce the volume of food you eat, and make you feel full quicker and for longer. The balloon is normally left in for 6-12 months. After this it must be removed as it may start breaking down.

Most people will have some short-term complications. These include abdominal discomfort and gastrointestinal symptoms like nausea, vomiting, acid reflux, and dehydration. You will be given medication to take home to help relieve these symptoms.

If symptoms don’t go away and you are vomiting, or unable to have any food or drink please go to an Accident and Emergency Department.

Other risks of having an intragastric balloon are: 

• Intestinal obstruction by the balloon.
• Bleeding or gastric perforation.
• Balloon rupture and migration.
• Gastric ulcers and oesophagitis.
• Sepsis.
• Pancreatitis.

The chance of these risks happening are very small, but you should be aware of them before agreeing to the procedure.

Once you have a date for your procedure, you will be sent an appointment to attend the pre-assessment clinic. A nurse and anaesthetist will check you are well enough to have surgery. You will be advised at your pre-operative assessment:

• When to stop eating and drinking before your operation.
• What medicines to take/not take on the day of the procedure.

The procedure is a day case and most people will go home that evening. Someone over the age of 18 years old will need to stay with you overnight as you will be having a general anaesthetic and may feel very sick.

After the procedure you will feel a little groggy but this will soon wear off.

You might feel quite thirsty and like your mouth is dry, but it is important not to drink quickly and gulp. This will make you be sick and might cause pain. Start with drinking some water from a tea spoon. Sip the fluid one spoon at a time and stop if you feel any pain. Slowly increase the amount of fluid that you are able to take.

If you get thirsty at home, make sure you keep sipping little and often and try sucking an ice lolly or ice cube.

After having the intragastric balloon inserted you may feel extreme nausea for up to 72 hours. It’s very important to take the following medication which will be given to you before leaving hospital:

• Proton Pump Inhibitor (protects your stomach):
  • Lansoprazole.
• Anti-sickness medication:
  • Cyclizine.
  • Ondansetron.
  • Prochlorperazine Buccal.

You will need to buy over the counter chewable A-Z multivitamins and take them twice a day. This will help you get enough vitamins while you are eating and drinking less. 

Once you have the balloon it is important to eat slowly and keep hydrated. Aim to drink 200mls an hour and avoid drinking 20 minutes either side of eating. Have a sip of water 30 minutes after eating to ‘rinse’ the balloon.

Remember, sip drinks slowly. You might find it helpful to carry a sports bottle around with you. Sips little and often are important to make sure that you stay well hydrated.

You need to follow a liquid and soft diet for the first 2 weeks after the balloon has been inserted. Then you can gradually move towards normal diet.

Days 1-7: runny fluids

• Water.
• Low calorie fruit squash.
• Weak tea or coffee.
• Clear soup or broth.
• Sugar-free jelly.
• Low fat/low sugar yoghurt drinks.
• Skimmed milk.
• Flavoured sugar-free water.

Day 8-10: thick fluids

Try introducing thicker fluids such as:

• Smooth soups such as tomato.
• Yoghurt drinks.
• Sloppy Ready Brek or Weetabix.
• Fruit and yoghurt smoothies.
• Milkshakes.

Day 11-14: soft food

Aim to gradually introduce soft textured food that can be mashed with the back of your fork. You will need to do this slowly. If you feel uncomfortable when you eat, take a break, wait, and then try another mouthful.

Here are some examples:

• Cottage cheese.
• Scrambled eggs.
• Porridge.
• Canned tuna with light mayonnaise.
• Lasagna.
• Bolognese sauce.
• Home made soups.

Day 15: solid food

Start introducing a diet of normal texture food, high in protein with the aim of a healthy balanced eating.

You will not feel like eating as much as before and if you eat fatty foods or sweets, you may feel nauseated.

Aim for 3 small meals a day with 2-3 high protein snacks if you can. Limit or avoid bread, pasta, and rice as these can stick to the balloon and cause bad breath and increase risk of nausea and heartburn.

A helpful technique to use is called ‘20, 20, 20 rule’. This involves:

1. Cutting your food to the size of a 20 pence piece.
2. Chewing 20 times before swallowing.
3. Leaving 20 minutes between bites.

An extra ‘20’ is to stop eating after 20 minutes to give you time to recognise how full you are feeling. You can always add a little more, but you want to avoid feeling overfull or being sick.

Regular overeating, to the point where you feel sick, can be dangerous with a balloon in place. If you are struggling to manage your eating, please reach out for support.

Drinking alcohol in moderation will not affect your balloon but the extra calories will not help your weight loss.

Possible problems

• Vomiting – if you vomit, stop eating for at least 2 hours then drink a small amount of water and proceed with soft foods again when you can. Aim to get back to solid foods. If the vomiting continues, or you are unable to drink fluids, contact your GP or go to A&E. Some people will need the balloon to be removed in the first few weeks because of severe nausea.
• Reflux – avoid eating late at night and wait at least 2 hours after eating before going to bed. The balloon tends to move up when you lie down and could cause reflux. If you have reflux in the evening avoid coffee, tea, and alcohol. Raise your bed at the head end and avoid certain foods which may make these symptoms worse.
• Smelly breath – this can be caused by food becoming trapped around the balloon. Try to drink water 30 minutes after eating to help clear the balloon.

The balloon can work as a tool to help you feel fuller for longer and reduce your overall food intake. If you are not noticing any difference in your hunger or fullness please contact the team for support.

The balloon will not necessarily take away the feeling of ‘head hunger’ or emotion-based urges to eat. These can be difficult to manage, please reach out to the team for support if you are struggling to manage these.

If you feel a craving coming on, you may find it helpful to focus on why you decided to start this journey and to have the balloon.

Think back to what has helped manage urges in the past, common techniques include:

• Identify the feeling: Is this a physical hunger? In which case, have a high-protein snack or meal. Is this a head hunger? Try the below:
  • Urge surfing: notice the feeling, rate the craving from 1-10, wait 20 minutes (distract yourself) then rate the feeling once again – usually it will have significantly reduced if not disappeared.
  • Distraction: arts and crafts, music, game on your phone, go for a walk, call a friend, taking yourself away from the kitchen/shops can be helpful.
  • Create an emotional toolbox: when I feel x (emotion) I will do x/y/z (action).
  • Plan your next meal/snack: sometime cravings happen when you are unsure where your next food is coming through – planning can help manage this.

Bariatric Coordinator:

• 0117 414 0855
• 0117 414 0854

Bariatric Clinical Nurse Specialist:

• 0117 414 7557
• 07557 312784