Insurance. Preparation. Do these things 7 DAYS BEFORE the procedure: Jerry Evans, MD, Department of Gastroenterology

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Eileen Stevenson
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1 Date of Procedure: Please arrive at St. Agnes Hospital at: Location: GI Endoscopy Services - Fourth Floor Diagnostic & Treatment Center - Elevator B IMPORTANT INFORMATION ABOUT YOUR SCHEDULED GI PROCEDURE Please note that you have been given an arrival time to the GI Endoscopy Services. Please expect to be in the GI area for a minimum of three hours. This will allow time to prepare you for the procedure, complete the procedure and monitor you prior to discharge. We make every effort to remain on schedule, but please understand that one person s findings may differ greatly from the next, which may necessitate a longer procedure time than scheduled. Also note that emergency procedures may have to be performed on patients and that may affect your procedure. Our goal is to provide every patient with a complete, thorough and safe examination. Insurance It is the responsibility of the patient to notify his/her insurance company of this procedure including benefit coverage for preventive and diagnostic procedures. Preparation For your bowel preparation, three prescriptions will be sent for you. Ondansetron (Zofran) is a pill used to minimize/prevent nausea. Nulytely/Trilytely/Gavilyte is the laxative solution you will drink to clean your colon. Bisacodyl is a pill used to help the laxative solution work more effectively. There are many different bowel preparations available. You will be prescribed Nulytely, Trilytely or Gavilyte based on your prescription drug coverage and what is most cost effective for you. All of these laxative solutions are a fast and effective way to cleanse your colon before a colonoscopy. The first bowel movement generally will occur approximately one hour after you begin drinking the solution. Do not be alarmed if your first bowel movement is not for three or four hours. Flushable wipes are recommended instead of toilet paper to minimize irritation that can result from the bowel preparation. Older bowel preparations that contained sodium phosphate, although less volume, have been associated with cases of kidney damage/electrolyte disturbances and subsequently may not be used. Do these things 7 DAYS BEFORE the procedure: You will need to find transportation home following your GI procedure. You will be receiving sedative medications that induce temporary amnesia and slow the response of your reflexes. Consequently, you will not be able to drive yourself home. It is also asked that due to sedation you do not work, drive or make important decisions for the rest of the day. Your ride home does need to be a friend or family member over the age of 18 years of age. For your safety, transportation by taxi or public transport is discouraged unless accompanied by a friend or family member. If you are unable to find transportation, contact the Fond du Lac Regional at (920) We recommend you have someone available immediately after the procedure to receive the results and follow-up care. Your physician will be available immediately after your procedure to provide the results of your examination to someone you have designated to receive this information. If a designated person is not available immediately following your procedure, the results, including follow-up care and/or next appointment, will be provided to you in a written format on your discharge instruction sheet. ADDITIONAL PREP INSTRUCTIONS ON NEXT PAGE.

2 Do these things 5 DAYS BEFORE the procedure: Stop taking iron and Vitamin E. Stop eating seeds, popcorn, nuts and whole grains. Do these things 3 DAYS BEFORE the procedure: Stop taking aspirin, Plavix or Coumadin (if you have been instructed to do so by our nursing staff). Stop taking all anti-inflammatory medicines. These include: Aspirin, Nuprin, Bufferin, Anacin, Advil, Motrin, Indocin, Aleve, Ecotrin, Alka Seltzer, Naprosyn, Voltaren. Tylenol is approved to take. If you have a colostomy, please plan to bring an extra stoma bag to your procedure. If you are diabetic, please discuss your medication regimen with us. If you require antibiotics before going to the dentist for a heart murmur, joint or heart valve replacement, please inform us prior to your procedure at (920) Confirm your ride. IF YOU NEED TO CANCEL your appointment, call Dr. Evans or his nurse at (920) You must call at least 72 hours prior to your procedure to cancel. This gives the clinic enough time to fill your scheduled time slot with another patient in need of a procedure. You will be contacted by telephone by the Pre-Admission department prior to your procedure to register you for your procedure. Review the diet you need to follow for the next two days. Plan you meals according to this diet. Do these things 2 DAYS BEFORE the procedure: For breakfast, lunch and dinner eat a low residue diet. (see attached list of foods) Drink at least eight glasses of water throughout the day. Take two bisacodyl tablets at bedtime. Do these things 1 DAY BEFORE the procedure: For breakfast and lunch eat a low residue diet. (see attached list of foods) Beginning at 1 p.m. and for the rest of the day: Start a strict, clear liquid diet (no solid foods). If you put a liquid in a clear glass and can see through it, it is OK to drink. A clear diet can include: Apple and white grape juice Beef or chicken broths that are clear Tea or coffee without milk Soda pop, Gatorade, Kool-Aid, popsicles, and various Jell-O flavors (any color except red) Avoid: juices with pulp, milk, cream and solid food Fill the plastic container containing the laxative powder (Nulytely/Trilytely/Gavilyte) with water, shake well until powder is dissolved. Add flavor pack if desired. Put container in refrigerator. ADDITIONAL PREP INSTRUCTIONS ON NEXT PAGE.

3 Do these things 1 DAY BEFORE the procedure: (cont.) At 3 p.m.: Take the first tablet of ondansetron (Zofran) by mouth with water. The ondansetron will help relieve nausea caused by drinking the laxative solution. At 4 p.m.: Start drinking the laxative (Nulytely/Trilytely/Gavilyte) solution. Drink one full glass every 15 to 20 minutes until you consume HALF. Try to drink one full glass at a time instead of sipping. You may continue to drink clear liquids for the rest of the day but do not eat any solid food. The laxative (Nulytely/Trilytely/Gavilyte) liquid will cause you to have many bowel movements. This is needed so you have a clean colon for the procedure so that any abnormalities, such as polyps, can be detected. If you have issues completing this preparation, call your doctor or nurse. Do these things ON THE DAY of the procedure: 5 hours prior to your procedure take the second tablet of ondansetron by mouth water. 4 hours prior to your procedure: Drink the remaining prep solution. Take your normal medications with sips of water. You may have clear liquids until two hours before your arrival time at St. Agnes Hospital (unless otherwise instructed). No solid foods. Bring your escort/driver with you to your appointment. If you are a female who is pre-menopausal, you will be asked to provide a urine sample prior to you procedure. Please arrive by the time listed for your procedure. Contacts If you have questions, please call our office at (920) Additional Information If a polyp is removed during your procedure, you will receive a letter from your physician. It may take up to 7 to 10 business days for you to receive your letter. You should take all of your medications like you normally take them, all the way up to day of the procedure. If you take oral medications for diabetes; do not take the morning of the procedure. You may take them when you get home. If you take insulin for diabetes; you should administer only HALF doses of your insulin the evening before and the morning of your procedure. Your blood sugar will be checked upon arrival for your procedure.

4 Restrooms Diabetes, Endocrinology and ID Services Corporate Care Ambulatory Infusion Anticoagulation Management West Agnesian Work & Wellness Occupational Health Consultants Laboratory Neurosurgery C Elevators Agnesian Pharmacy Plus Gift Shop Info Desk- Fond du Lac Regional Registration Medical Imaging PASS Diagnostic & Treatment Center Elevators B Women s Imaging Outpatient Therapy Patient Experience Volunteer Services Hospital Registration St. Agnes Hospital South Building Elevators Fond du Lac County Virtual A Restrooms Restrooms Journeys: a health resource center Café Coffee Info Desk- Hospital St. Agnes Chapel Take elevator B to GI Lab - Fourth floor Samaritan Health Emergency Department Emergency Department &After-Hours

5 LOW RESIDUE DIET FOR COLONOSCOPY PREP Food Group Foods Allowed Foods to Avoid Milk and dairy Beverages Breads, cereals & starches Fruits Milk and milk products: Cow s milk Ice cream Yogurt Cheese Cream Coffee and tea Carbonated beverages Apple juice Strained juice Bottled water Tomato juice Fruit drinks without pulp, such as fruit punch Kool-Aid or Hi-C (without red dye) Nutritional supplements without added fiber, such as Boost or Ensure Refined breads, rolls, bagels, English muffins, pita bread, biscuits, muffins, crackers, pancakes, waffles or pastries Refined cooked and cold cereals, such as hominy grits, farina, Cream of Wheat or rice, strained oatmeal, Cheerios, Corn/rice Chex, cornflakes, Rice Krispies, Special K Potato and sweet potato without skin White rice Refined pasta Canned or cooked fruit without skins or seeds (peaches, pears, apricots, apples) Applesauce Ripe banana Jellied cranberry sauce Fruited yogurt Any ice cream or cheese with nuts or seeds Any milk products if lactose intolerant Any beverage containing pulp or seeds, such as orange or grapefruit juice Prune juice Nutritional supplements that contain fiber Whole grain breads, cereals and pasta Oatmeal Granola Any bread, cereal, cracker or pasta made with seeds, nuts, coconut or raw or dried fruit Corn bread Graham crackers Brown rice Wheat germ Bran Sprouted wheat Wild rice Barley Potato skins Raw fruit (bananas are OK) Canned pineapple, oranges, grapefruit sections, mixed fruit Dried fruit All berries, melons Whole cranberry sauce Avocado Coconut

6 LOW RESIDUE DIET FOR COLONOSCOPY PREP, CONT. Food Group Foods Allowed Foods to Avoid Vegetables Meat & meat substitutes Miscellaneous Tender, well-cooked, fresh, canned and frozen vegetables without seeds, such as peeled carrots, green beans and beets Strained vegetable juice Strained tomato sauce Cooked, tender fish, poultry, beef, lamb, pork, ham, veal, organ meats Eggs Cheese Tofu Tuna fish Smooth peanut butter and other smooth nut butters Salt, sugar, ground or flaked herbs and spices Vinegar Ketchup and mustard Soy sauce Jelly (not jam or preserves) All raw vegetables, such as lettuce, onion, celery, cucumber, mushrooms, scallions, etc. Vegetables with seeds Tough, fibrous cooked vegetables, such as: Artichokes Broad beans Brussels sprouts Corn Eggplant Onion Sauerkraut and cabbage Tomatoes Asparagus Broccoli and cauliflower Celery Cucumber Mushrooms Peas (green peas) Spinach Zucchini summer squash Winter squash Non-tender meats Gristle Hot dogs Salami, cold cuts Meat substitutes made with whole grains, nuts or seeds Dried beans, peas, lentils Crunchy-style peanut butter and other crunchy nut butters Pepper Seed spices Seeds and nuts Coconut Popcorn Jams or preserves Pickles and olives

sure you take all the right steps to be prepared for your procedure. The steps include:

sure you take all the right steps to be prepared for your procedure. The steps include: 330 Brookline Avenue Boston, MA 02215 (617) 667-5711 Phone Dear Patient, Thank you for choosing Beth Israel Deaconess Medical Center for your barium enema procedure. We want to make sure your procedure