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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.