Colon Prep: GoLytely Extra Dose (1.

5-Gallons)
(Follow same instructions for Nulytely/Trilyte/Gavilyte/Peg 3350 Substitutes)

Dr. Chua Dr. Cuschieri Dr. Ghorai Dr. Hawkins Dr. Loura Dr. Mu Dr. Slosberg Dr. Wakelin

Calendar Dates 07/24/2024 07/28/2024 07/29/2024

General instructions 5 DAYS PRIOR: 1 DAY PRIOR: PROCEDURE DATE:
Medical Instructions Preparation Day Instructions Day of procedure Instructions
To view Golytely Extra Dose prep From This Day On, Until The 7 AM: Mix both GoLytely containers Early morning: take your usual prescribed
video: Procedure: with 1 gallon of water each and store medication except for blood thinners, insulin or
https://www.wwmedgroup.com/pre- TURN PAPER OVER FOR LOW in refrigerator. oral diabetic medication, unless told otherwise by
procedure-instructions/ FIBER DIET your doctor.
Entire Day: Clear liquid diet (no solid
OK to continue clear liquid diet.
5 BUSINESS DAYS PRIOR: Last chance to STOP:_______________________ foods!): clear fruit juice without pulp
cancel appointment or you will be charged For _____ days before procedure. such as apple juice, white grape juice, SIX HOURS PRIOR TO YOUR CHECK IN TIME:
a LATE CANCELLATION FEE of $250. broth, Gatorade (No Gatorade Frost), From the Mylicon box you will fill the 0.6 ml
Stop taking Phentermine, oil
Check with insurance in advance to see if supplements, oil capsules, and iron
popsicles, coffee or tea without syringe five times adding each to the
you need a referral or pre-approval for pills. cream. Small amount of Jell-O is OK. remaining Golytely container. Drink the
your procedure. No milk, red, blue, or purple colors. remaining 6 glasses of GoLytely, one 8 oz.
If you are diabetic or if you’re taking glass every 15 to 20 minutes until it is gone.
Please leave jewelry, money, and other blood thinners and you did not If you take diabetic medication(s):
valuables at home. receive specific instructions regarding Refer to the instruction sheet DO NOT stop the prep even if you think your stool
your medications, please call the "Colonoscopy Patients with Diabetes". is clear, as fecal matter often comes out
If you have an ostomy, we recommend
bringing extra ostomy supplies with you. office. Blood thinners include Plavix, intermittently. A good prep should result in
Effient, Warfarin (Coumadin),
12 Noon: drink the 1st half gallon of CLEAR yellowish watery stool (not cloudy) that
If you have an electronic stimulator, bring Pradaxa, or Xarelto, etc. GoLytely, 8 oz. glass every 15 to 20 looks like clear urine.
your wand/device to turn off your minutes as tolerated for a total of 8
stimulator. If you have implantable cardiology glasses. Discard the remainder FOUR HOURS PRIOR TO YOUR CHECK IN
devices (defibrillator or pacemaker), solution. TIME ABSOLUTELY NOTHING BY MOUTH
Secure a driver for the procedure day, as notify the office as a device clearance (e.g. gum, hard candy, chewing tobacco,
it is unsafe to drive for 12 hours after the is needed from your cardiologist. 6 PM: drink 2nd gallon of GoLytely, 8 water, etc.).
procedure. oz. glass every 15 to 20 minutes as
OPTIONAL: You may take OTC AGAIN, be sure to bring:
SUPPLIES: MiraLAX one dose in a 8 oz. glass of tolerated. Finish 10 glasses and save
the remaining 6 glasses for the ● Medication list
● 2 Gallons - GoLytely or a generic water up to 3 times per day as ● A driver
equivalent (prescription) needed to maintain daily soft BMs. morning.
● Photo ID/Insurance card
● Infant Mylicon Gas Relief Drops You may also use your usual laxatives ● Eyeglasses/Hearing aids
What to expect: It may take several
15 ML (OTC) as needed.
hours before you have multiple bowel
● MiraLAX (OTC), optional You CANNOT drink alcohol or drive for 12 hours
If you have severe constipation, call movements. Expect lots of diarrhea.
● Fleet enema (OTC), optional after the test.
office for advice (425) 259-3122. *This is normal*
NO ALCOHOL
CPT Codes: Colonoscopy 45378-45385; ICD-10 codes: screening Z12.11; Hx Polyps Z86.010; Fx Polyps Z83.71; Fx Colon CA Z80.00; Other:____________
NEWLY REVISED 11/14/2023
 LOW FIBER DIET
General Rule: DO NOT eat anything with any of the following ingredients: nuts, seeds,
raw fruits with seeds, raw vegetables, corn, beans (example: kidney, pinto, lima),
whole grains, or popcorn.

BELOW ARE THE ONLY ALLOWED FOODS

BREADS ETC:
● White breads, rolls, biscuits MEAT/PROTEIN:
● Waffles, French toast, pancakes ● Well cooked, lean meats, fish
● White rice, white pasta, peeled cooked potatoes ● Eggs
● Saltines or white crackers without seeds ● Creamy peanut/almond butter
● Hot cereal: cream of rice, cream of wheat ● Tofu
● Cold cereal: Rice Krispies, Corn Flakes, Special K
FATS, SWEETS, CONDIMENTS, BEVERAGES:
VEGETABLES AND FRUITS: ● Margarine, butter, cooking oils, mayonnaise, salad dressing
● Plain gravies
● Cooked and canned vegetables –carrots, green beans,
● Sugar, clear jelly, honey and syrup
spinach
● Soups made with allowed vegetables, broth
● Applesauce
● Coffee, tea, carbonated beverages
● Apple or white grape juice ● Plain cake
● Bananas ● Gelatin, plain pudding, popsicles
● Cantaloupe, honeydew melon
● Hard candy, pretzels
● Plain chocolate
MILK/DAIRY:
● Milk: plain or flavored, coconut, almond, soy
● Yogurt, custard and ice cream
● Cheese and cottage cheese

11/14/2023