Download Pill Cam preparation - Metro Atlanta Gastroenterology

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
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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
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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
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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)
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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.