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Metro Atlanta Gastroenterology Metro Atlanta Endoscopy, LLC 404.255.4333 PATIENT INSTRUCTIONS FOR SB CAPSULE ENDOSCOPY Your physician has determined that as part of your medical evaluation you should undergo an examination known as SB Capsule Endoscopy. The procedure involves ingesting a small capsule (the size of a large vitamin pill)which will pass naturally through your digestive system while taking pictures of the intestine. After approximately 8 hours, you will return to our office to have the RecorderBelt removed. The actual capsule is disposable and will be excreted naturally in a bowel movement . In very rare cases it will not be excreted naturally, it would then need to be removed endoscopically or surgically. In order for your physician to get the most accurate information from this examination please carefully follow the directions below. The day before the capsule endoscopy Abstain from smoking 24 hours prior to undergoing your capsule endoscopy. After lunch(12-1 pm) on the day before the SB capsule exam start a clear liquid diet The day of your capsule endoscopy Do not eat or drink after midnight DO NOT TAKE ANY MEDICATION 2 hours before your exam Wear loose fitting, two-piece(pants and a shirt), cotton clothing to the exam. If you prefer to wear the belt under your shirt then you will need to also wear a cotton undershirt or tank top. Arrive at Metro Atlanta Gastroenterology 7:30-7:45 AM(it is important that you arrive no later than 7:45. After ingesting the capsule Do not eat for 6 hours You may drink clear liquids 4 hours after ingestion Call 404.255.4333 if you experience abdominal pain, nausea or vomiting. Do not go near any strong electromagnetic fields(such as a MRI or radio transmitter) Do not disconnect, remove, or reposition the equipment Avoid sudden movement and banging of the DataRecorder. Page Two After ingesting the capsule(continued) Please check your recorder every fifteen minutes to insure that the small blue light on top of the recorder is blinking twice per second. If it is not, record the time and please call our office. Please record time and nature of any event such as eating, drinking, and any activity which produces unusual sensations. Avoid strenuous physical activity, perspiring and DO NOT BEND OR STOOP during your exam. Return to Metro Atlanta Gastroenterology @ 4:00 PM(please arrive on time) Metro Atlanta Gastroenterology LLC 404-255-4333 5669 Peachtree Dunwoody RD STE 210 Atlanta, GA 30342 CONSENT FORM I CONSENT TO HAVING CAPSULE ENDOSCOPY. Capsule Endoscopy is an endoscopic exam of the small intestine. It is not intended to examine the esophagus, stomach, or colon. It does not replace upper endoscopy or colonoscopy. I understand that there are risks associated with any endoscopic examination, such as BOWEL OBSTRUCTION. An obstruction may require immediate surgery. I am aware that I should avoid MRI machines during the procedure and until the capsule passes following the exam. I understand that due to variations in a patient’s intestinal motility, the capsule may only image part of the small intestine. It is also possible that due to interference, some images may be lost and this may result in the need to repeat the capsule procedure. I understand that images and data obtained from my capsule endoscopy may be used, under complete confidentiality, for educational purposes in future medical studies. Dr. ______________ has explained the procedure and its risks to me, along with alternatives of diagnosis and treatment, and I have been allowed to ask questions concerning the planned examination. I authorize Dr. _________________________ to perform capsule endoscopy. Patient’s Name (please print) In presence of: 1201 Spouse Parent Patient’s Signature _____ _____ Companion Patient Alone Date _____ _____ Metro Atlanta Gastroenterolgy LLC 5669 Peachtree Dunwoody RD STE 210 Atlanta, GA 30342 404-255-4333 Capsule Endoscopy Intake Form NEW PATIENT ____ EXISTING PATIENT ____ MALE ________ Date: Age: Patient Name Referring MD Address D.O.B. City/State/Zip S.S.# Telephone # Home Telephone # Work FEMALE ________ INDICATION FOR C.E. Patient History 1. Do you have a history of bowel obstruction? Y N 2. Have you had bowel or intestinal surgery? Y N Type of surgery: ____________________________________________________________________ Any complications? ___________________________________________________________________ 3. Have you had abdominal radiation therapy? Y N 4. Have you previously had a capsule Endoscopy, or swallowed any other ingestible device? Y N 5. Do you take insulin? (dose: Y N 6. Have you ever taken NSAIDs, such as Advil or Indocin, or aspirin for more than 30 days? Y N 7. Do you have a pacemaker or other implanted medical device? Y N 8. Do you have a history of Crohn's disease? Y N 9. Are you currently taking prescription pain medications? Y N ) A ‘YES’ answer to any of the above questions should be brought to MD's attention. These are NOT DEFINITIVE contraindications, but the MD should be aware. Metro Atlanta Gastroenterology Metro Atlanta Endoscopy, LLC AUTHORIZATION TO CHARGE CREDIT CARD DATE:_______________ PATIENT:______________________________________________ Acct.:_____________________ I authorize Metro Atlanta Gastroenterology to charge my credit card $800.00 if I lose, damage or do not return the PillCam Data Recorder and all associated equipment today by 4:00 pm. Cardholder’s Name:________________________________________________________ Type of Card: Visa Master Card Discover Credit Card #:______________________________________ Exp Date:_________________________ CARDHOLDER’S Signature:___________________________________ Date of Signature:____________________ Metro Atlanta Gastroenterology LLC 404-255-4333 5669 Peachtree Dunwoody RD STE 210 Atlanta, GA 30342 Post Capsule Endoscopy - Patient Instructions You have just undergone capsule Endoscopy. This sheet contains information about what to expect over the next two days. Please call our office if you have severe or persistent abdominal or chest pain, fever, difficulty swallowing, or if you have any questions. Our phone number is 404.255.4333. 1. Pain: Pain is uncommon following capsule endoscopy. Should you feel sharp or persistent pain, please call our office. 2. Nausea: Nausea is also very uncommon and should it occur, please notify the office. 3. Diet: You may eat and drink as normal. There are NO dietary restrictions. 4. Activities: Following the exam, you may resume normal activities, including exercise. 5. Medications: You may resume all medications immediately. Do not make up for doses you have missed, just begin your normal dosage. 6. Further Testing: Until the capsule passes, any type of MRI should be avoided. If you have an MRI examination scheduled within the next 3 days, it should be postponed, unless you visualized the capsule pass OR passage is confirmed by x-ray. 7. The Capsule: The capsule passes naturally in a bowel movement, typically in about 24 hours. Most likely, you will be unaware of its passage. It does not need to be retrieved and can safely be flushed down the toilet. Occasionally, the capsule lights will still be flashing when it passes. In the absence of symptoms, should you be concerned that the capsule did not pass; an abdominal x-ray can be obtained after 14 days to confirm its passage.