Form 51090 2/20

SUPREP COLONOSCOPY INSTRUCTIONSPlease read and follow these instructions carefully.

Procedure Date:_______________________ Check-In Time:______________ Dr.____________________________

Please contact the Anticoagulation Clinic or the physician who manages your blood thinning medication for instructions.

NOTE: Before you stop taking your coumadin / warfarin, please contact the doctor who prescribed them.

5 days prior to your procedure:

Stop all Iron (ferrous sulfate) supplements. Multi-vitamins containing iron are OK. Please also stop all fish oil and other herbal medications.

No nuts, seeds or popcorn from now until after your procedure.

MEDICATIONS 4 DAYS PRIOR 3 DAYS PRIOR 2 DAYS PRIOR 1 DAY PRIOR PROCEDURE DAY

Fill your prescriptions.

Diet:Begin a low fiber diet (see attached low fiber diet sheet)

No nuts, seeds or popcorn from now until after your procedure.

Cancellations:Please cancel your appointment, if you will not be able to make it.

Diet: Continue the low fiber diet. Ride home: You MUST have a responsible adult accompany you to your appointment.

If you show up without one, your appointment will be cancelled. Taxi cabs are not legal escorts.

Diet: Continue the low fiber diet.

Hydrate:Drink at least 4-6 (8 oz.) glasses of water or clear liquids throughout the day.

Begin a clear liquid diet. (See attached clear liquid diet sheet.)

Diabetics: Please see the enclosed instructions.

Throughout the day drink 4-6 (8 oz.) glasses of water or clear liquids.

9:00 pm:Take 125mg Simethicone and drink the first dose of SUPREP as directed on the “SUPREP BOWEL PREP KIT” instruction sheet provided in your instructions and information packet.

The prep may cause side effects such as bloating, cramping and nausea.

Early morning:Take your usual prescribed medication (especially blood pressure medication) with a sip of water. Except diabetics. See enclosed instructions

You may continue to have clear liquids until 2 hours prior to your arrival time.

3 hours before leaving home:Take 125mg Simethicone and then drink SUPREP dose #2.

Al this point, you will have finished taking the SUPREP. If your stool is not clear or light yellow, please call the office ASAP.

Within 2 hours of check-in time:Nothing by mouth

Tips for Preparation 3 Please follow these instructions instead of any instructions

provided separately with the SUPREP itself or by the pharmacy.

3 Responses to the prep vary. Bowel movements will begin in 30 minutes to 6 hours following ingestion of the preparation.

3 Drink 4-6 (8 oz.) glasses of water or clear liquid the day before your procedure. The more fluids you drink the better your prep will be.

3 Tucks medicated pads help relieve anal soreness during bowel preparation.

Location: o Confluence Health x Wenatchee Valley Hospital & Clinics o Moses Lake Clinic o Omak Clinic 820 N. Chelan Avenue, 509-436-4024, 4th floor; Hospital side. 840 Hill Avenue 916 Koala Drive Please use the elevators near the Bistro 509-764-6400 509-826-1800

FILL

LIN

E IMPO

RTAN

T

(17.

5g/3

.13g

/1.6

g) pe

r 6 o

unce

s

SUPR

EP B

owel

Prep

Kit i

s a sp

lit-do

se (2

-day

) reg

imen

. Both

6-o

unce

bottl

es ar

e req

uired

for a

comp

lete p

rep.

FIRS

T DO

SE: B

egin

Step 1

at _

____

__PM

the e

venin

g bef

ore y

our p

roce

dure

and p

roce

ed as

show

n belo

w:

You m

ust c

omple

te Ste

ps 1

thro

ugh 4

using

one (

1) 6

-oun

ce bo

ttle b

efor

e goin

g to b

ed:

SECO

ND D

OSE:

Beg

in Ste

p 1 at

___

__AM

the m

ornin

g of y

our p

roce

dure

and p

roce

ed as

show

n abo

ve:

For t

his do

se, r

epea

t Step

s 1 th

roug

h 4 sh

own a

bove

using

the o

ther

6-o

unce

bottl

e.

NOTE

: You

mus

t fi n

ish dr

inking

the fi

nal

glass

of w

ater a

t leas

t ho

ur, o

r as d

irecte

d, be

fore

your

colon

osco

py.

Pour

ONE

(1) 6

-oun

ce

bottl

e of S

UPRE

P liqu

id int

o the

mixi

ng co

ntain

er.

STEP

1

Drink

ALL

the l

iquid

in th

e con

taine

r.

STEP

3

Add c

ool d

rinkin

g wate

r to

the 1

6-ou

nce l

ine on

the

cont

ainer

and m

ix.

NOTE

: Dilu

te th

e solu

tion

conc

entra

te as

dire

cted

prior

to us

e.

STEP

2

You m

ust d

rink t

wo (2

) mo

re 1

6-ou

nce c

ontai

ners

of w

ater o

ver t

he ne

xt

1 ho

ur.

STEP

4

(Plea

se se

e ot

her p

age

for a

dditi

onal

inst

ructi

ons.)

HEAL

THCA

RE P

ROVI

DER

INFO

RMAT

ION

Name

:

Addr

ess:

City:

State:

Zip:

Phon

e:

Fax:

2s

FILL

LIN

E IMPO

RTAN

T

(17.

5g/3

.13g

/1.6

g) pe

r 6 o

unce

s

SUPR

EP B

owel

Prep

Kit i

s a sp

lit-do

se (2

-day

) reg

imen

. Both

6-o

unce

bottl

es ar

e req

uired

for a

comp

lete p

rep.

FIRS

T DO

SE: B

egin

Step 1

at _

____

__PM

the e

venin

g bef

ore y

our p

roce

dure

and p

roce

ed as

show

n belo

w:

You m

ust c

omple

te Ste

ps 1

thro

ugh 4

using

one (

1) 6

-oun

ce bo

ttle b

efor

e goin

g to b

ed:

SECO

ND D

OSE:

Begin

Step

1 at

___

__AM

the m

ornin

g of y

our p

roce

dure

and p

roce

ed as

show

n abo

ve:

For t

his do

se, r

epea

t Step

s 1 th

roug

h 4 sh

own a

bove

using

the o

ther

6-o

unce

bottl

e.

NOTE

: You

mus

t fi n

ish dr

inking

the fi

nal

glass

of w

ater a

t leas

t ho

ur, o

r as d

irecte

d, be

fore

your

colon

osco

py.

Pour

ONE

(1) 6

-oun

ce

bottl

e of S

UPRE

P liqu

id int

o the

mixi

ng co

ntain

er.

STEP

1

Drink

ALL

the l

iquid

in th

e con

taine

r.

STEP

3

Add c

ool d

rinkin

g wate

r to

the 1

6-ou

nce l

ine on

the

cont

ainer

and m

ix.

NOTE

: Dilu

te th

e solu

tion

conc

entra

te as

dire

cted

prior

to us

e.

STEP

2

You m

ust d

rink t

wo (2

) mo

re 1

6-ou

nce c

ontai

ners

of w

ater o

ver t

he ne

xt

1 ho

ur.

STEP

4

(Plea

se se

e ot

her p

age

for a

dditi

onal

inst

ructi

ons.)

HEAL

THCA

RE P

ROVI

DER

INFO

RMAT

ION

Name

:

Addr

ess:

City:

State:

Zip:

Phon

e:

Fax:

2s

FIRS

T DO

SE:

Even

ing

befo

re c

olon

osco

py

SECO

ND D

OSE

: M

orni

ng o

f col

onos

copy

Form

494

59

4/15

Form

495

00 (M

LC)

4/17

Bill

ing:

• P

leas

e no

te th

at s

cree

ning

col

onos

copi

es a

re o

ften

not s

ubje

ct to

ded

uctib

les,

co-

pays

or c

o-in

sura

nce.

We

will

al

way

s try

to b

ill a

scr

eeni

ng c

olon

osco

py a

s a

scre

enin

g co

lono

scop

y.•

How

ever

, if a

pol

yp n

eeds

to b

e re

mov

ed o

r bio

psie

s ne

ed to

be

done

dur

ing

the

colo

nosc

opy,

then

by

law

we

are

oblig

ated

to u

se th

e co

de fo

r “c

olon

osco

py w

ith p

olyp

ecto

my”

or

“col

onos

copy

with

bio

psy.

” In

suc

h ca

ses,

de

duct

ible

s, c

o-pa

ys a

nd c

o-in

sura

nce

may

app

ly. P

leas

e co

nsul

t with

you

r ins

uran

ce c

ompa

ny fo

r det

ails

.

Impo

rtan

t Inf

orm

atio

n A

bout

You

rC

olon

osco

py P

roce

dure

Und

erst

andi

ng c

olon

osco

pyC

olon

osco

py is

an

outp

atie

nt p

roce

dure

use

d to

scr

een

for

colo

n ca

ncer

and

als

o to

eva

luat

e ga

stro

inte

stin

al

sym

ptom

s su

ch a

s bl

eedi

ng, a

bdom

inal

pai

n, o

r cha

nges

in

bow

el h

abits

. Dur

ing

colo

nosc

opy,

a lo

ng, t

hin,

flex

ible

tu

be is

pas

sed

into

you

r col

on. A

cam

era

on th

e en

d of

th

e in

stru

men

t allo

ws

the

doct

or to

exa

min

e yo

ur c

olon

on

a h

igh-

reso

lutio

n m

onito

r. P

olyp

s or

abn

orm

al ti

ssue

ca

n be

bio

psie

d or

rem

oved

.C

ompl

icat

ions

dur

ing

colo

nosc

opy

are

extre

mel

y ra

re,

but

incl

ude

blee

ding

, pe

rfora

tion,

and

hea

rt an

d lu

ng

prob

lem

s as

soci

ated

with

the

seda

tion.

Ben

efits

of c

olon

can

cer s

cree

ning

Col

on c

ance

r is

one

of

the

mos

t co

mm

on c

ance

rs i

n bo

th m

en a

nd w

omen

and

is th

e se

cond

lead

ing

caus

e of

can

cer-

rela

ted

deat

h in

the

Uni

ted

Sta

tes.

The

goo

d ne

ws

is t

hat

mos

t co

lon

canc

ers

can

be p

reve

nted

th

roug

h ro

utin

e sc

reen

ing,

with

col

onos

copy

the

mos

t ac

cura

te t

est

for

the

early

det

ectio

n an

d pr

even

tion

of

colo

n ca

ncer

. Col

onos

copy

allo

ws

for t

he d

iagn

osis

and

re

mov

al o

f pre

canc

erou

s po

lyps

, the

pre

curs

or o

f col

on

canc

er. C

olon

can

cer s

cree

ning

is p

artic

ular

ly im

porta

nt

beca

use

mos

t col

on p

olyp

s do

not

cau

se s

ympt

oms.

If

colo

n ca

ncer

is fo

und

early

, it i

s hi

ghly

trea

tabl

e.C

olon

osco

py is

not

a p

erfe

ct te

st th

ough

. Due

to s

harp

co

rner

s an

d bl

ind

spot

s in

the

col

on,

and

subo

ptim

al

prep

arat

ion

of t

he c

olon

in

som

e ca

ses,

eve

n in

the

ha

nds

of e

xper

t col

onos

copi

sts,

ther

e ca

n be

up

to a

5

to 1

0% m

iss

rate

for p

olyp

s.D

rink

all t

he p

rep

It is

ver

y im

porta

nt th

at y

ou fi

nish

all

of th

e co

lono

scop

y pr

ep s

olut

ion,

eve

n if

you

thin

k yo

ur s

tool

s ar

e cl

ear.

Thou

gh y

our s

tool

s m

ay a

ppea

r cle

ar to

you

, com

plet

ion

of t

he e

ntire

pre

p is

usu

ally

nec

essa

ry f

or a

tho

roug

h co

lono

scop

y ex

amin

atio

n w

ith a

min

imal

cha

nce

of

mis

sing

som

ethi

ng. T

he p

oore

r th

e qu

ality

of t

he p

rep,

th

e gr

eate

r ch

ance

that

a s

igni

fican

t les

ion

in th

e co

lon

coul

d be

mis

sed.

Seda

tion

durin

g co

lono

scop

yC

olon

osco

py

is

gene

rally

pe

rform

ed

with

m

oder

ate

seda

tion,

not

ane

sthe

sia.

Med

icat

ions

are

adm

inis

tere

d th

roug

h an

IV.

Our

goa

l is

to

keep

you

com

forta

ble

durin

g th

e co

lono

scop

y, n

ot u

ncon

scio

us. M

ost p

atie

nts

are

very

dro

wsy

or

even

asl

eep

durin

g th

e pr

oced

ure.

S

ome

patie

nts

rem

ain

awak

e, b

ut re

laxe

d. B

ecau

se th

e se

dativ

es im

pair

mem

ory,

mos

t pat

ient

s do

not

rem

embe

r th

eir c

olon

osco

py.

Pre-

colo

nosc

opy

• P

leas

e pi

ck

up

your

co

lono

scop

y pr

ep

from

th

e ph

arm

acy

as s

oon

as p

ossi

ble.

Pha

rmac

ies

will

hol

d a

pres

crip

tion

for

a sh

ort t

ime

and

then

ret

urn

it to

the

shel

f. If

your

pre

p is

n’t a

t the

pha

rmac

y, p

leas

e ca

ll ou

r de

partm

ent a

t (50

9) 7

64-6

418.

• Ig

nore

any

ins

truct

ions

pro

vide

d se

para

tely

with

the

co

lono

scop

y pr

ep it

self

or b

y th

e ph

arm

acy.

The

se m

ay

confl

ict w

ith th

e in

stru

ctio

ns w

e ha

ve p

rovi

ded

to y

ou.

• W

hen

you

sche

dule

you

r ap

poin

tmen

t, yo

u ar

e gi

ven

an a

rriv

al ti

me.

Not

e th

at th

is is

an

estim

ated

tim

e. S

ome

proc

edur

es a

re m

ore

com

plic

ated

and

may

take

long

er

than

exp

ecte

d, r

esul

ting

in d

elay

s to

the

sch

edul

e.

Ple

ase

be u

nder

stan

ding

, if t

his

is th

e ca

se. W

hen

you

chec

k in

, ou

r st

aff

will

giv

e yo

u an

upd

ated

pro

cedu

re

time.

• Our

nur

ses

will

cal

l you

2 d

ays

prio

r to

your

col

onos

copy

to

revi

ew th

e pr

ep p

roce

ss a

nd a

nsw

er a

ny q

uest

ions

.• I

f you

are

una

ble

to m

ake

your

colo

nosc

opy a

ppoi

ntm

ent,

we

requ

est t

hat y

ou c

ance

l you

r app

oint

men

t at l

east

72

hour

s in

adv

ance

.Po

st-c

olon

osco

py• A

fter y

our p

roce

dure

, you

will

be

take

n to

the

reco

very

ar

ea. Y

ou w

ill b

e gi

ven

som

ethi

ng to

drin

k an

d D

r. C

ohen

w

ill r

evie

w y

our

colo

nosc

opy

resu

lts w

ith y

ou p

rior

to

disc

harg

e.• Y

ou w

ill n

ot b

e ab

le to

driv

e, ru

n m

achi

nery

, sig

n le

gal

docu

men

ts, o

r wor

k un

til th

e da

y af

ter y

our c

olon

osco

py.

The

proc

edur

al m

edic

atio

ns w

ill s

till b

e in

you

r sy

stem

an

d m

ay i

mpa

ir yo

ur r

eflex

es,

judg

men

t, an

d de

pth

perc

eptio

n.• Y

ou w

ill re

ceiv

e a

phon

e ca

ll fro

m u

s th

e da

y fo

llow

ing

your

col

onos

copy

, to

see

how

you

are

doi

ng.

5/31

/201

5 M

LC

PRE-

COLO

NOSC

OPY

INST

RUCT

IONS

FO

R DI

ABET

IC P

ATIE

NTS

Di

abet

ics

on d

ieta

ry

cont

rol o

nly:

• N

o ch

ange

s to

usu

al

prep

.

• B

lood

sug

ar w

ill b

e ch

ecke

d on

arr

ival

.

Diab

etic

s on

ora

l hy

pogl

ycem

ic a

gent

s:

• Ta

ke u

sual

dia

betic

m

edic

ine

the

mor

ning

of

the

prep

, the

n no

dia

betic

m

edic

ines

unt

il af

ter t

he

colo

nosc

opy.

• B

lood

sug

ar w

ill b

e ch

ecke

d on

arr

ival

.

Diab

etic

s on

insu

lin:

• Ta

ke o

ne h

alf o

f you

r us

ual i

nsul

in d

ose

the

day

befo

re y

our p

roce

dure

. Do

not t

ake

insu

lin th

e m

orni

ng

of th

e co

lono

scop

y.

• B

lood

sug

ar w

ill b

e ch

ecke

d on

arr

ival

.

• Milk, cream, chocolate milk, hot chocolate, milk-based drinks

• Cheese, cottage cheese• Broth• Yogurt, sour cream

• Custard or pudding• Ice cream or frozen desserts• Cream sauces• Soups without seeds or beans

• Yogurt with granola, seeds, nuts or fruit with skin in them

Breads, Grains • Breads and grains made from refined or white flour including: rolls, bagels, muffins (no bran), English muffins

• Cheerios, Rice Crispies

• Whole wheat or grains with seeds including: rolls, bagels, muffins, English Muffins

• Oatmeal

Fruit • Soft canned or cooked fruit without seeds or skins• Soft melon• Fruit juice without pulp• Fruit jellies without pulp

• All other raw fruits• All dried fruits• Fruit juice with pulp

Vegetables and potatoes

• Potatoes without skin• Vegetable juice without pulp

• All raw or steamed vegetables• Beans, peas• Potatoes with skin• Brussel sprouts• Corn (!)

• Broccoli, cauliflower

• Cabbage, onion• Sauerkraut• Greens or lettuce

Meat, Fish, Poultry, Protein

• Tender beef, ground beef• Chicken• Pork• Eggs

• Fish and shellfish• Creamy peanut butter• Lamb• Tofu

Fats & Oils • Butter• Salad dressings without seeds or nuts

• Nuts (!)• Seeds (!)• Coconut

• Sugar• Salt• Jelly

Miscellaneous • Jam• Marmalade• Relishes

Why do I need to eat a low fiber diet? It is very important to begin a low fiber diet 4 days before your colonoscopy. Fiber is indigestible and stays inside the colon, making the colonoscopy less accurate.

LOW FIBER DIETFood Group OK to Eat Do NOT Eat

• Corn flakes• Crackers• Pasta• Cream of Wheat

• Raisin Bran, All Bran• Wheaties• Granola• Popcorn• Brown rice, wild rice

• Tough meat with gristle• Chunky peanut butter• All beans, nuts, peas, lentils, legumes

• Prune juice• Prunes• Bananas

• Margarine• Oil• Mayonnaise

• Salad dressing with nuts or seeds

• Honey• Syrup• Lemon juice

• Pickles• Olives

Milk,Dairy Products

Form 49345 11/15

CLEAR LIQUID DIETIt is especially important to avoid clear liquids with red or purple dyes.

• Water• Flavored waters (without red or purple dyes)• Clear Broths (chicken, beef, or vegetable broth)• Juices (without pulp and without red or purple dyes) 3Apple 3White Grape 3Lemonade without pulp• Sodas• Gatorade• Tea (with sugar OK)• Coffee (black; with sugar OK)• Gelatin i.e. Jello (without fruit; no red or purple dyes)• Popsicles (without fruit or cream; no red or purple dyes)• Italian Ices (without red or purple dyes)• Coconut water

• Milk (no cow, soy, almond, rice, hemp milk)• Cream• Milkshakes• Ice cream• Smoothies• Orange juice• Grapefruit juice• Tomato juice• Soups other than clear broth

Why do I need to follow a clear liquid diet? A clear liquid diet is necessary during colonoscopy preparation to provide needed fluids. Clear liquids are easy to digest and leave little or no residue in the digestive tract. Clear liquids are liquids that you can see through. For example, coffee is a clear liquid, but coffee with cream or milk is not. You will be starting your clear liquid diet the day before your exam.

OK to Eat Do NOT Eat

PRE-COLONOSCOPY ORDERS FOR DIABETIC PATIENTSDiabetics on Insulin:• Take one half of usual insulin dose the

day before exam. Do not take insulin the morning of the colonoscopy.

• FSBS to be checked on arrival.

Diabetics on oral hypoglycemic agents:• Take usual diabetic medicine the morning

of the prep, then no diabetic medicines until after the colonoscopy.

• FSBS to be checked on arrival.

Diabetics on dietary control only:• No changes in usual prep.• FSBS to be checked on arrival.