Instructions for Colonoscopy and possible Biopsy and Polypectomy
ThinkPark Tower Gastroenterology Clinic
3rd floor ThinkPark Tower Medical Center room#1
2-1-1 Osaki Shinagawaku, Tokyo 141-6003 Japan
phone 03-5745-3088 Fax 03-5745-3089
HP: http://www.thinkparkclinic.com
info@thinkparkclinic.com
cell 090-9954-6303 Email: lisana773@gmail.com
Patient Name: ___________________________________
Appointment date and time: _____/_____/______ at_____:____ [ ] am [ ] pm
Welcome to ThinkPark International Clinic. You have been scheduled for a procedure called aColonoscopy. This procedure usually takes approximately 20 minutes. Be sure to bring thequestionnaire and documents provided with you on the day of your procedure.

< What is a Colonoscopy? >A colonoscopy is a test that allows your doctor to look inside your large intestine, also
called the colon and rectum using a colonoscope that is a thin, flexible tube that
ranges from 48 in. (125 cm) to 72 in. (183 cm) long. A small camera is attached to thecolonoscope so that your doctor can take pictures of the large intestine (colon andrectum). A colonoscopy helps find ulcers, colon polyps, tumors, and areas ofinflammation or bleeding, and can also be used as a screening test to check forcancer or precancerous growths in the colon or rectum (polyps). During acolonoscopy, tissue samples can be collected (biopsy) and abnormal growths can betaken out (polypectomy).
It is done to find out the reason for:• constipation, or diarrhea• nausea or vomiting• abdominal pain or cramp• bleeding• ulcers, enterocolitis, viral or bacterial infections or inflammations• Irritable bowel syndrome (IBS), Diverticulosis, Ulcerates colitis (UC), Crohn's disease(CD), Ischemic Colitis• screening of cancers or tumors< Risks >A colonoscopy is a very safe procedure. However, there are some complications that
may occur:•Bloating, abdominal cramps, pain１•Reaction to the medications, such as a temporary inflammation of the vein at the IVsite.
•Slowing of the heart rate, a decrease in breathing, or drop in blood pressure
temporally.
Serious medical problems occurring rarely include:•Tear in the wall of the colon called a perforation. If this occurs, it is generally treatedwith hospitalization and antibiotics or surgery.
•Bleeding may also occur. Intravenous administration and diet restriction as well asother procedures may be needed to stop the bleeding during following days. In rarecases, a lot of bleeding can occur after a biopsy. If a polyp is removed, the risk of atear or bleeding is increased.
Although colonoscopy is generally an accurate examination, it is possible someabnormalities may not be detected.
< One Week Before Colonoscopy >•If you take Plavix, Coumadin (Warfarin), Aspirin or any other blood thinning
medications, please discuss with the doctor who proscribed these medications if you
could temporally stop the medication a week before the procedure to prepare for abiopsy or polypectomy.
•Purchase colon cleansing preparation “MOVIPREP” and diet product“ENEMACLIEAN” at our clinic.
•Start a LOW fiber diet, such as white rice, white bread, sandwiches, cooked cereal,soup, stew, cooked fish or tender chicken, egg, tofu etc. (page5), for at least 3 days
prior to your procedure.
•If you do not regularly have a daily bowel movement or suffer from constipation,
you need to start a LOW fiber diet earlier and consult a doctor to be given additional
Laxative.
< One Day Before the Procedure >Eat a LOW fiber diet (page5) or a clear liquid diet only, finish eating before 6:00 PM. It
is recommended that you try to avoid eating in general but if you feel it is necessarythen please feel free to eat low-fiber diet. Drink as much “transparent” liquid, such aswater, soda, or sports drinks (GATORADE or POCARI SWEAT etc.) (page5) as possible
throughout the day (no milk, densely colored liquids, concentrated liquids or juices).

２< Colonoscopy Preparation >It is recommended to start bowel prep such as MOVIPREP at least three hours prior to aprocedure.

< Instruction for MOVIPREP >1) Open the aluminum bag, and take off the cap on the plastic container. Pour water to thestar mark★.
2) After you put the cap back on tightly, push pouch A into pouch B to mix the agent andwater.
3) Shake the solution until the agent is dissolved.
4) Open the cap and pour additional water to the top line showing two litters total andmake sure the solution dissolves completely. If preferred, mix solution ahead of time andrefrigerate prior to drinking. The solution should be used within 24 hours.
• Drink the MOVIPREP solution slowly, 8 oz. (180ml) every 10-15 minutes until the entire
solution in the bottle is consumed. While you drink the prep solution, take enough water toprevent dehydration (a glass of water is recommended following every 2 glasses ofreagent). This reagent will cause you to have loose stools and you will need to use thebathroom often. The bowel prep may be uncomfortable, but you should drink all of it or until
excretion liquid becomes clear to ensure an adequate preparation.
• If you have abnormal symptoms such as nausea, vomiting, strong abdominal pain, paleness,chills, facial swelling, choking, urticaria etc., stop drinking MOVIPREP, and contact your doctor
or medical assistance.
•Take the cardiac medications such as nitroglycerin anti-hypertensive regularly. Do nottake diabetic medications while fasting. Ask about any individual medical questions you
might have.
< During the Colonoscopy >•Take off any accessories you are wearing such as rings, neckless, glasses or dentures,
if possible, and safely keep them by yourself.
•You will lie on your left side with your knees bent for the colonoscopy.
•An intravenous (IV) line will be put in your arm. You will be given medications
through the IV that will help you relax and may make you drowsy.
•The doctor will insert the colonoscope into your rectum and colon.
•You may feel some stomach discomfort or cramping. This will go away
after your procedure.
•You may feel drowsy for a short time after the procedure.
•Your blood pressure and heart rate will be checked.
•You will have to pass gas before you go home.
３< After the procedure >•You may have some abdominal bloating after the procedure.
•You may have a small amount of blood from the rectum.
•If you receive procedural sedation that will make you sleepy and drowsy, you will not
be able to drive afterwards. If you have someone available to drive you home oraccompany you home in a taxi or on any public transportation after your procedure, itwill be necessary.
•You may only eat easily digestible foods as a part of your diet or only liquid (NoAlcohol) after the biopsy or polypectomy unless otherwise directed by the doctor.
•You may return to work the next day and resume your normal activities.
< After the polypectomy >About 30 percent of people who are screened for colorectal cancer are found tohave polyps. In five to ten years, some of these polyps may become cancer. If
colorectal cancer is found at an early stage, a person may have a 95% chance ofliving longer than five years. If colorectal cancer is found at a late stage, a person
may have only a 10% chance of living for five years. If cancer is present, the earlier it
is found, the better the outcome. Because most polyps have no symptoms, it's very
important to have a colorectal cancer screening to find and remove polyps before
they have a chance to develop into cancer. On occasion, the doctor can remove
early cancerous (malignant) growths in the same manner.

When a doctor finds polyps or tumors and removes them during the colonoscopy, itcauses no pain. However, the discomforts including pressure, bloating, and/orcramping, which will go away with the passing of gas.
At home:•Expect a complete recovery in one week. Avoid any alcohol, spices, spicy foods,and fiber-rich foods (You might have to return if you need additional clinicaltreatment or intravenous feeding for a week following surgery).
•Also exercise and sports (Exercise such as heavy lifting, jogging, golfing and longdrives) must be avoided.
•Start drinking and eating slowly by taking one bite or sip at a time pausing between
to see your stomachs reaction. Eat a softened or easily digestible diet such as soupsor sports drinks for at least 2-3 days following the surgery.
•Your doctor will discuss the results of the pathology in a week.
If you have urgent symptoms such as the following, stop eating and contact medical
professionals immediately:• Severe increasing pain
• Excessive bleeding or continuing black, tarry stools• Hard, swollen abdomen or severe nausea or vomiting４

< Low-Fiber Diet > < Foods Recommended >Breads, Cereal, Rice and Pasta:• White bread, rolls, biscuits, croissants, toast and pancakes •White rice, noodles, pasta,
macaroni and peeled cooked potatoes • Plain crackers and Saltines •Cooked cereals
Milk/Dairy:• Milk, plain or flavored • Yogurt, custard and ice cream • Cheese and cottage
cheeseFats, 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, bullion, broth or lightclear soups without solid particles • Coffee, tea and carbonated drinks • Plain cakes
and cookies • Gelatin, plain puddings, custard, ice cream, sherbet and popsicles• Candy or pretzels • Ketchup and mustard
Meat and other proteins:• Ground, well-cooked tender beef, lamb, ham, veal, pork, fish or poultry • Eggs
•Tofu

< Foods to Avoid > < Fiber-rich diet >Breads, Cereal, Rice and Pasta:• Breads or rolls with nuts, seeds or fruit • Whole wheat, rye breads and cornbread • Potatoes with skin, brown or wild rice
Vegetables:• Raw or steamed Vegetables with seeds • winter squash, peas, broccoli, Brussels
sprouts, cabbage, onions, cauliflower, baked beans, peas and corn
Fruits:• Prunes and prune juice •Raw or dried fruit •All berries, figs, dates and raisins

Fats, Snacks, Sweets, Condiments and Beverages:• Nuts, seeds and coconut • Jam, marmalade and preserves • Pickles, olives, relishand horseradish • All desserts containing nuts, seeds, dried fruit, coconut or madefrom whole grains or bran • Candy made with nuts or seeds • Popcorn
Meat and other proteins:• Tough, fibrous meats with gristle • Dry beans, peas and lentils • Peanut butter with nuts

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ThinkPark Tower Gastroenterology Clinic

Patient Questionnaire and Consent Form
Name________________________________ ☐ Male ☐ Female
Date of Birth_______________________________ years oldAddress__________________________________________________________________________
Phone number_________________________• Current Medications, Prescription / Over the Counter
Medication Name
Dose

Last Time Taken___________________________ ___________________ ________________________________________________ ___________________ ________________________________________________ ___________________ ________________________________________________ ___________________ _____________________•Are you taking blood thinning medications such as Plavix, Coumadin (Warfarin), Aspirin or any others?
Medication Name

Dose

Last Time Taken___________________________ ___________________ _____________________•Personal Medical History. If checked, please explain☐ High Blood Pressure ()☐ Diabetes()☐ Heart Disease()☐ Lung Disease()☐ Liver Disease()☐ Kidney Disease ())☐ Others)☐ Allergies ((☐ Anesthetic/side effect or allergy ()☐ Surgical Histories ()☐ Pregnant ()Prostatic Hypertrophy ()I understand the professional will do the best and appropriate managements under this procedure if any
unexpected conditions occur. I was informed the benefits and risks of the performance and agree to havethis procedure. I will follow the instruction direct by Doctors and Medical assistances.

Signature_______________________________ date_________________
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