Colonoscopy Procedure Preparation Checklist

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Colonoscopy Procedure Preparation Checklist

5 days before your procedure

READ THE PREPARATION INSTRUCTION SHEETS

Arrange for a ride home. If you do not have a responsible adult to take you home, your procedure will have to be rescheduled.

Stop taking medications like aspirin, Aleve, ibuprofen, any other anti- inflammatory medicine, Plavix , Aggrenox (or any other antiplatelet drug), vitamin E, iron, and all herbal supplements.

If you are taking Coumadin, stop taking it now and make sure you have an appointment to have your PT/INR drawn on the day before your procedure.

Continue your other medications for your heart, blood pressure, asthma, and other chronic medical conditions as usual, unless otherwise instructed by your physician.

Purchase TriLyte (Polyethylene glycol electrolyte solution) at your pharmacy. Prescription is included in this packet.

3 days before your procedure

Confirm your ride.

Drink lots of fluids throughout the day.

Start the Low Fiber/Low Residue diet at breakfast and continue today & tomorrow.

2 days before your procedure

Continue the Low Fiber/ Low Residue diet.

If you usually have constipation, take 2 tablespoons of milk of magnesia at 8pm.

1 day before the procedure

Start a strict clear liquid diet. No solid food. Start your prep as you have been instructed.

Drink lots of clear fluids throughout the day.

Complete the Medical History form included in the packet.

If you stopped taking Coumadin 4 days ago, come in to the lab for a PT/INR test.

On the day of the procedure

4 hours before your procedure, finish drinking the prep solution.

If you take a diuretic medication or a medication that has a diuretic in it (Lasix, HCTZ, etc), DO NOT take it this morning. You can take it after your procedure is done.

Take your other normal medications except for the ones that you were instructed not to take (such as anti-inflammatory medications, aspirin, blood thinner, Plavix, diuretic) with a sip of water at least 2 hours before your procedure.

Do NOT eat or drink anything 2 hours before your procedure.

Bring your driver, insurance card, hospital card (if you have one), and completed Medical History form with you to your appointment at UNC Hillsborough Medical Office Building (460 Waterstone Drive Hillsborough).

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Chapel Hill Internal Medicine

940 Martin Luther King, Jr. Blvd Chapel Hill, NC 27514

919-942-5123

COLONOSCOPY INSTRUCTIONS: TRILYTE SPLIT DOSING

Your GI procedure will be performed at UNC Hillsborough Medical Office Building. Most procedures last between 30-60 minutes. Please plan to spend ~3 hours at the procedure unit. You should arrive at the GI Procedure check-in desk at least 45 minutes prior to your scheduled appointment. This is to ensure that we have adequate time to get you ready for your procedure. You MUST have a DRIVER to take you home and the driver must remain on the premises during the procedure.

Five (5) days before your procedure

 STOP taking the following medications:

o Anticoagulants: Coumadin (warfarin), Lovenox

 If you take Coumadin, PT/INR will need to be checked day before your procedure.  If you are taking Lovenox, discuss this in advance with your gastroenterologist.

o Anti-platelet drugs: Aspirin, Aggrenox, Plavix, Ticlid, Pletal® (cilostazol), Jantoven®, Ticlid®,

o Non-steroidal arthritis medicines: Ibuprofen, Motrin, Advil, Naproxen, Celebrex, Mobic (ask about specific drugs so we can check our list).

o Iron supplements and all multivitamins that contain iron, calcium, Vitamin E.

o All herbal and homeopathic supplements.

 It is OK to take Acetaminophen (Tylenol and Tylenol Extra Strength).

 Continue your medications for your heart, blood pressure, asthma, or other chronic medical conditions as usual, unless otherwise instructed by your physician.

 Purchase TriLyte (Polyethylene glycol electrolyte solution) at your pharmacy. Prescription is included in this packet. Please call the office if you do not have the prescription.

Three (3) days before your procedure

 Eat low fiber/low residue diet for the next two days.

Foods you can eat

 White bread, Rolls, Crackers, Pastas, Potatoes without skins, white rice

 Ready-to-eat cereals (corn flakes, rice crispies, cheerios, etc; no nuts or seeds).  All strained fruit juices except prune juice

 Cooked and Canned fruits and vegetables without seeds or tough skin (no prunes)  Applesauce/ ripe banana/ soft honeydew/ soft cantaloupe/ ripe avocado

 Meat / Poultry / Fish / Eggs / Tofu

 Creamy peanut butter, almond butter, etc.  Butter / margarine

 Milk and milk products / Cottage cheese / Cheeses / Yogurt - limit to 2 cups a day  Coffee, Tea, Broth, Vegetable juices

Foods you CANNOT eat on your low fiber/ low residue days:

 NO Whole wheat bread, Whole wheat cereals, Brown rice, Popcorn  NO Baked goods with seeds, nuts, oatmeal, or coconut

 NO NUTS OR SEEDS OF ANY KIND (sesame, poppy, walnut, peanuts, etc.)  NO Flaxseeds - NO Olives - NO Prunes

 NO Meat or Shellfish with tough connective tissue, such as Beef flank steak or shrimp

 NO SALADS, MUSHROOMS, TOMATOES, CORN, CUCUMBERS, SWEET POTATOES  NOTHING THAT HAS A SEED, SKIN, OR LEAF ATTACHED TO IT.

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If you usually have constipation, take 2 tablespoons of milk of magnesia at 8pm.

One (1) day before your procedure

Begin a clear liquid diet. It is important to drink plenty of clear liquids. NO SOLID FOOD.

o Allowed and Recommended Clear Liquids

Beverages: Water, coffee, or tea (no milk or non-dairy creamer); Strained fruit juices /no pulp (apple, white grape, lemonade); Soft drinks/Sports drinks (Pedialyte, Gatorade G2) Soups: Chicken or Beef bouillon/broth, strained canned soups

Desserts: Jell-O (lemon, lime, orange, NO fruit, NO toppings); Popsicles (NO sherbets, NO fruit bars)

o Avoid liquids with red or purple coloring

o No solid foods allowed, including milk/milk products  PREP INSTRUCTIONS

1. In the morning,fill the one-gallon container containing the laxative powder (TriLyte) with water to the marked line. Shake well until the powder is dissolved. Trilyte solution is a total of 1 gallon (128 ounces) of fluid. This measures out to sixteen 8-oz glasses of solution. Put the container in the refrigerator so that it will be chilled when it is time to start drinking it.

2. At 5 pm, begin drinking 8-oz glass of TriLyte solution every 10-15 minutes for a total of 12 glasses. 3. You may notice some bloating or cramping at the beginning of the prep, but this should go away once

the bowel evacuation begins. If you experience any nausea, slow down to drinking a glass of solution every 20-25 minutes

4.

After you finish this segment of the colon prep, you may continue to drink clear liquids until bedtime.

Day of your procedure

1. Four hours before you leave for your procedure, drink the remaining four 8-oz glasses of TriLyte solution (15 minutes apart).

2. You may continue to drink clear liquids up to 2 hours before your procedure. Do NOT eat or drink

anything 2 hours before your procedure.

3. Blood pressure medications should be taken unless they are a diuretic (hydrochlorothiazide, Lasix, or furosemide) or have a diuretic in it. These drugs with diuretics should be taken after your procedure.

4. Take your normal morning medications, with the exception of those listed above, with a sip of water at least 2 hours before your procedure.

5. If you have diabetes, your medication may need to be adjusted.

For morning appointments: patients taking insulin should take ½ the usual dose the night before, and no insulin in the morning. Oral diabetic medication should be held the night before and on the morning of the procedure.

For afternoon appointments – Insulin should be ½ the dose on the night before and ½ the dose on the morning of the procedure. Oral diabetic medication should be held the night before and on the morning of the procedure.

**If you have further questions or concerns about your diabetic medication management, please contact your primary care provider for further instructions**.

The GOAL of the Preparation is to have a clean bowel. This means that what is being evacuated is a clear liquid with a slight green or yellow tint. There should be no solid material in your stool. If you are passing solid particles on the morning of your procedure, you will need to take a tap water enema.

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Chapel Hill Internal Medicine

940 Martin Luther King, Jr. Blvd Chapel Hill, NC 27514

919-942-5123

Medical History Form

***please complete and bring with you to your GI procedure appointment***

Patient’s name: _______________________________________ Date of birth______________________ Referring physician:_________________________ Primary care provider: __________________________

Allergies: � None. � Yes: __________________________________________________________________

 Have you ever had a reaction to anesthetic, including Midazolam(Versed) and Fentanyl or Meperidine (Demerol) ? � Yes � No. If yes, please describe_____________________________________________________________________________________ Medications (List all current prescription and non-prescription medications. Attach additional pages if necessary)

Medication Name Dosage Frequency/day Medication Name Dosage Frequency/ Day

Are you currently taking blood thinners (Coumadin/Warfarin, Plavix, Aggrenox, Ticlid)? � Yes � No Are you currently taking aspirin/NSAIDs (Ibuprofen, Advil, Naprosyn, Aleve, etc.)? � Yes � No Medical History (Which of the following conditions are you currently being treated or have been treated for in the past?)

� Crohn’s disease � Ulcerative colitis � Colon cancer � Colon polyps � Diverticulitis � Hepatitis B � Hepatitis C � Liver problems

� Heart attack � Arrhythmia � Hypertension

� History of endocarditis � Emphysema/COPD/Asthma � Diabetes

� Stroke

� Seizure disorder

� Kidney disease � Anemia

� Bleeding disorder � Blood clots

� Cancer____________________ � Other: ____________________ � Other: ____________________ � Other: ____________________

Past Surgical History (Include year surgery was performed)

� Colon resection

� Small bowel resection/surgery � Appendectomy

� Cholecystectomy (gallbladder surgery)

� Hemorrhoidectomy � Gastric bypass � Pacemaker � Defibrillator

� Artificial heart valve � Joint replacement � Hysterectomy

� Other:_____________________

Past GI Procedures Year & where it was performed Results if known

Colonoscopy Upper Endoscopy Sigmoidoscopy

Do you take antibiotics prior to dental work? � Yes � No. If so, why?_______________________________

FEMALE PATIENTS: Are you now, or is there a possibility that you may be pregnant? � Yes � No

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GI Procedures at UNC Hillsborough Medical Office Building

Your GI procedure will be performed at UNC Hillsborough Medical Office Building. Most procedures last between 15 - 60 minutes. Please plan to spend ~3 hours at the procedure unit. We will do everything possible to avoid a delay in your procedure, but emergencies may interrupt the schedule.

Frequently Asked Questions:

1. Where do I go?

Your procedure will be performed at UNC Hillsborough Medical Office Building located at 460 Waterstone Drive Hillsborough, NC 27278 phone # 919-595-5900).

Directions from the North (Durham)

 Take I-85 South

 Take Exit 164 for Hillsborough

 Go Left onto old NC 86 (also known as Churton St)

 Go to the 4th light and turn Left onto Waterstone Drive

 The building and parking lot will be on your right Directions from the South (Pittsboro)

 Take 15-501 North toward Chapel Hill

 Merge onto 15N/501N/Fordham Blvd toward Durham

 Turn Left onto I-40 West and follow the directions from the East below Directions from the East (Raleigh)

 Take I-40 West toward Greensboro

 Take Exit 261 for Hillsborough

 Bear Right off of the exit onto old NC 86 (also known as Churton St)

 At the first light turn right onto Waterstone Dr.

 The building and parking lot will be on your right Directions from the West (Greensboro)

 Take I-40 East/ I-85 North towards Raleigh/Durham

 At the I-40/I-85 split stay to the right onto I-40 East towards Raleigh

 Take exit 261 for Hillsborough

 Turn Left off the exit onto old NC 86 (Churton St)

 At the first light turn Right onto Waterstone Dr.

2. When should I arrive?

We ask that you arrive at the GI Procedure check-in desk at least 45 minutes prior to your scheduled appointment. This is to ensure that we have adequate time to get you ready for your procedure. 3. What should I bring with me?

Unless you plan to have a procedure without sedation (which is rare), you must be accompanied by an adult who must stay on the premises during the procedure and drive you home after it is completed. You should also

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bring your insurance card, hospital card (if you have one), a completed pre-procedure questionnaire, and either a credit card, debit card, or checks for any possible out-of-pocket payments.

4. What happens after I arrive and check-in?

After you check-in you will be brought to the pre-procedure area where a nurse will ask you several questions, check your blood pressure, and place an IV. You will also meet with a gastroenterologist who will discuss the procedure with you, examine you, and obtain your consent. Next, you will be brought to the procedure room and meet a GI procedure nurse and GI technician. Just before the procedure starts you will be given medicine to make you comfortable, and then the procedure will be performed. Most procedures last between 15 - 60 minutes. During this time, your accompanying adult will be asked to wait in the waiting area or elsewhere on premises (she or he must be reachable by cell phone).

5. What happens after the procedure is completed?

After the procedure is completed you will be brought to the recovery area, where you will fully awaken from the procedure, meet the adult who accompanies you, and remain for approximately 20-45 minutes. Your GI physician will discuss the results with you. After you have fully recovered, a nurse will answer any additional questions, review a set of printed post-procedure instructions (covering diet, activity, and medication use), and send you home. If you received sedative medications (almost all patients do) you will not be able to drive. Instead, your accompanying adult will drive you home. Staff members are available to help you to your car, if necessary.

6. How long will the whole process take?

Please plan to spend at least 3 hours at the GI procedure unit. We will do everything possible to avoid a delay in your procedure, but emergencies may interrupt the schedule.

7. Can I drive myself home after my procedure?

NO. If you received medication for the procedure (most people), you cannot drive after the test and must instead arrange for someone to drive you home. Your driver must remain on the premises during the procedure. 8. How much will this cost me?

Out-of-pocket costs vary depending on your insurance and the type of procedure. A letter regarding possible procedure costs will be mailed to you within 4 weeks of your scheduled procedure. For additional questions or assistance, please call UNC financial counselor at 919-595-5902.

9. Can I eat after my procedure?

Most patients can resume a normal diet after the procedure. Your physician or nurse will give you specific dietary instructions after the procedure is completed.

10.When can I return to work?

If you receive sedative medications (most people) you may return to work the following day 11.Biopsies were taken. When can I expect to receive these results?

In general you will receive the results of any biopsies (tissue samples) by mail, approximately 2-4 weeks after the procedure. If you do not receive these results by then, please call us at 919-942-5123.

12.What if I need to reschedule my appointment?

Please call us at 919-942-5123 as soon as possible (and at least 3 days before the scheduled appointment). If you need to cancel or change your appointment on the day of the procedure, please call UNC GI Procedure at 919-966-5563.

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