Board Certified Specialists in Gastrointestinal and Liver Disease

SUPREP SPLIT DOSE “6 and 6” PREP

Your procedure is scheduled for ___________________________________________________

at _________________________________ with ______________________________________ PRE-OP AT SAME DAY SURGERY________________________________________________ You may call your procedure site at ____________________________________________ if you do not hear from them by 3:00 PM on ______________________________________.

THEY WILL GIVE YOU YOUR TIME OF ARRIVAL. PLEASE DO NOT CALL BEFORE 3:00 PM. A. PREPARATION FOR THE TEST 1. a. Notify the doctor if you take Plavix, Coumadin (warfarin) on a daily basis. b. Notify the doctor if you take insulin or other diabetic medications on a daily basis. c. Notify the doctor if you take Adipex, Phentermine, or other appetite suppressants. These medications should be stopped 2 weeks prior to your procedure. d. Changes in these medicines are as follows: ________________________________________________________________________ ________________________________________________________________________ 2. The point of the prep is to clean your bowel out COMPLETELY, so that the doctor can see the instrument camera! By the time you are finished, you should be passing only clear or slightly “Mello Yellow” colored watery fluid. There should be NO stool or pieces of stool present whatsoever. If there is, see Section F below. Your preparation is critical for the success and accuracy of the exam. DO NOT TAKE ANY OIL-BASED SUPPLEMENTS FOR 1 WEEK PRIOR TO YOUR EXAM. THIS INCLUDES: MINERAL OILS, FISH OILS, AND OIL-BASED ENEMAS. IF YOU TAKE OIL-BASED PRODUCTS WITHIN 1 WEEK PRIOR TO YOUR EXAM, THE PHYSICIAN MAY CANCEL YOUR PROCEDURE DUE TO THE NEGATIVE EFFECTS THAT OILS HAVE ON THE OPTICS OF THE SCOPE. Your physician has recommended a split dose (2-Day) SUPREP regimen. Both doses are required for a complete prep. The first dose will be at 6PM the day before your procedure and the second dose will start 6 hours before you arrive for the procedure. 3. Purchase SUPREP bowel prep kit at the pharmacy with a prescription. Follow instructions on this page, NOT what comes from the pharmacy. 4. Starting at 6:00 a.m., _______________________________________________________ (4 days before

your procedure), please start eating foods listed in the “foods to choose” column highlighted on the low residue diet paperwork enclosed in your packet. Please follow the low residue diet for the next 3 days.

5. Starting at 6:00 a.m., ______________________________________________________ (the day before the procedure), you may have ONLY clear liquids such as: water, apple juice, grape juice, gingerale, 7-UP, chicken or beef broth, Jello gelatin (no solid fruit pieces and no pudding), black coffee (no cream), tea, or

soft drink - diet or regular. Gatorade is a preferred choice. NOTHING RED IN COLOR. Please consume at least 8 ounces per hour until midnight.

6. (1

ST DOSE) At 6:00 PM on the day before your procedure___________________________,

complete the following 4 steps: • Step 1. Pour ONE (6) ounce bottle of SUPREP liquid into the mixing container. • Step 2. Add cool drinking water and fill to the 16 oz. line on the container and mix. • Step 3. Drink ALL of the liquid in the container beginning at 6PM. • Step 4. You MUST drink two (2) more 16 oz. containers of water over the next hour.

YOU MAY CONTINUE CLEAR LIQUIDS FROM THIS POINT UNTIL THE SECOND DOSE OF PREP.

7. (2nd DOSE) ON THE MORNING OF YOUR PROCEDURE 6 hours before your arrival time

on_________________________________________, repeat the same steps 1-4, (the other bottle of SUPREP).

• Step 1. Pour ONE (6) ounce bottle of SUPREP liquid into the mixing container. • Step 2. Add cool drinking water and fill to the 16 oz. line on the container and mix. • Step 3. Drink ALL of the liquid in the container beginning 6 hours before your arrival time. • Step 4. You MUST finish drinking two (2) more 16 oz. containers of water over the next hour. *Step 3 and 4 can be completed over a two hour time period but you must be completely finished with the prep and additional water no later than 4 hours before you arrive for your procedure. Failure to do so may result in postponing or cancelling your procedure.* DO NOT DRINK ANYTHING AFTER YOU HAVE FINISHED THE SECOND DOSE OF PREP AND WATER. FAILURE TO FOLLOW THESE INSTRUCTIONS MAY RESULT IN POSTPONING OR CANCELLING YOUR PROCEDURE! B. You may want to sleep on a pad or towel due to possible seepage. C. You may use Tucks for irritation. D. Take your usual medication with a sip of water on the morning of the test (UNLESS YOU

RECEIVE INSTRUCTIONS NOT TO). If you are on inhalers at home, please take your normal

dose in the morning before you come to the Endo Unit for your procedure, and bring your inhaler with you. IF YOU HAVE SLEEP APNEA AND USE CPAP, BRING YOUR MACHINE WITH YOU. E. Make arrangements for someone to stay at our facility while you are here so that the doctor can speak with them after your procedure. Someone will need to drive you home after the procedure (no cabs). You CANNOT DRIVE for the rest of the day of your test. F. If you do not feel that you have been cleaned out well, please let the receptionist know when you arrive for your procedure. G. It is common to have minor problems such as nausea and occasional vomiting when taking a bowel prep. If this occurs, you can take a short break to give your body time to adjust to the prep and then restart. It is important to try to drink all of the prep (both doses) so that your doctor can provide a thorough exam. If you vomit your prep (either the first or second dose) after you have kept most of it down and the prep results are clear, there is no need to call the doctor. However, if your prep results are not clear and you are vomiting the prep; or if you have severe problems with the prep, call the doctor on call at 828-315-5000. The doctor may order enemas to ensure an adequate bowel prep. H. Please leave all jewelry at home. This includes: rings, necklaces, and body piercings. Do not wear makeup or nail polish the day of the test. Artificial nails do not need to be removed. I. For answers to frequently asked questions about the procedures, and for information about common gastrointestinal problems, please visit our website at www.gastro-associates.net DUE TO LIMITED AVAILABLITY, OUR PROCEDURE APPOINTMENT TIMES ARE VERY VALUABLE. YOU MUST GIVE 5 WORKING DAYS NOTICE IF UNABLE TO KEEP THIS APPOINTMENT. FAILURE TO DO SO WILL RESULT IN A $200.00 CHARGE FOR TIME RESERVED.

Revised 11/22/17

SUPREP SPLIT-DOSE “6 and 6” PREP Page 2 of 2

Gastroenterology Associates, P.A. 415 North Center Street, Suite 300 • Hickory, NC 28601

828-328-3300 www.gastro-associates.net

Low-Residue/Low-Fiber Diet

A low-residue/low-fiber diet will help you clean you intestines more easily. A low-residue/low-fiber diet limits the amount of food

waste that has to move through the large intestine.

Points to Keep in Mind

-Avoid any food made with seeds, nuts, or raw or dried fruit.

-Avoid whole-grain breads and cereals. Purchase products made from refined flour.

-Do not eat raw fruits or vegetables. Remove skins before cooking.

-Limit milk and milk products to 2 cups a day.

-Limit fats since these can increase stool bulk.

-Avoid tough, fibrous meats with gristle.

Types of Foods Foods to Choose Foods to Avoid

Breads, Cereals, Rice and Pasta

6-11 servings each day

Serving size:

-1 slice of bread

-1 cup cooked cereal, rice or

pasta

-Enriched white bread, rolls,

biscuits and muffins

-Waffles, French toast, and

Pancakes

-White rice, noodles, pasta and cooked

potatoes (no skin)

-Plain crackers

-Cooked cereals: farina, cream of wheat,

and grits

-Cold cereals: Puffed rice, Rice Krispies,

Corn Flakes, and Special K

-Breads or rolls with nuts, seeds or fruit

-Whole wheat, pumpernickel bread, and

cornbread

-Potatoes with skin, brown or wild rice,

and kasha (buckwheat)

-Whole grain cereals, bran cereals,

granola-type cereals, and cereals with

nuts, seeds, coconut, or dried fruit.

Fruit

2-4 servings each day

-Strained fruit juice

-Canned or cooked fruits without skins or

seeds

-Ripe banana

-Soft cantaloupe and honeydew melon

-Prunes and prune juice

-Raw or dried fruit

-All berries and raisins

Milk and Dairy Products

2 servings each day

Serving size:

-1 cup milk or yogurt

-1/2 ounces of cheese

-Milk, plain or flavored

-Yogurt, custard and ice cream

-Cheese and cottage cheese

-Yogurt with nuts or seeds

Vegetables

3-5 servings each day

Serving size:

-1/2 cup cooked vegetables

-Strained vegetable juice

-Well-cooked fresh or canned vegetables

such as asparagus tips, beets, green

beans, carrots, acorn squash (without

seeds), pureed spinach, and tomato

sauce

-Lettuce if tolerated

-Raw or partially cooked (steamed)

vegetables

-Vegetables with seeds

-Sauerkraut

-Cooked peas, winter squash, broccoli,

brussel sprouts, cabbage, onions,

cauliflower, baked beans and corn.

Types of Foods Foods to Choose Foods to Avoid

Meats, Poultry, Fish, Dry Beans, Peas

and Eggs

2-3 servings or a total of 6 ounces daily

Serving size:

-2-3 ounces, cooked

-Count 1 egg, 1/2 cup cooked beans, or 2

tablespoons peanut butter as 1 ounce of

meat

-Ground , well-cooked, tender beef,

lamb, ham, veal, pork, fish, poultry, and

organ

-Eggs

-Tough, fibrous meats with gristle

-Dry beans, peas, and lentils

-Peanut Butter

Fats, Snacks Sweets, Condiments and

Beverages

-Margarine, butter, oils, mayonnaise,

sour cream, and salad dressing

-Plain gravies

-Sugar, clear jelly, honey and syrup

-Spices, cooked herbs, bouillon, broth,

and soups made with allowed

ingredients

-Coffee, tea, and carbonated drinks

-Plain cakes and cookies

-Gelatin, plain puddings, custard, ice

cream, sherbet, popsicles

-Hard Candy

-Pretzels

-Nuts, seeds and coconut

-Jam, marmalade, and preserves

-Pickles, olives, relish and horseradish

-All desserts containing nuts, seeds,

dried fruit, coconut or made from whole

grains or bran

-Candy made with nuts or seeds

-Popcorn

Meal Portions

Breakfast -1/2 cup frozen orange juice (strained without pulp) -1 cup cream of wheat

-1 scrambled egg -1 slice of white bread

-1 teaspoon margarine and grape jelly -1 cup milk

-drinks of choice

Lunch -1/2 cup apple juice -3 ounces baked chicken

-baked potato (no skin) -1/2 cup cooked green beans

-1 slice white bread -2 teaspoon margarine

-1/2 cup sherbet -drinks of choice

Dinner -3 ounces tender roast beef -1/2 cup white rice

-1/2 cup cooked carrots -1 slice white bread

-1 teaspoon margarine -1/2 cup canned pears

-drinks of choice

Evening Snack -1 cup milk -4 graham crackers

Sample Menu

Rev 10.17.17