PREPARATION FOR ESOPHAGEAL MOTILITY STUDY

Transcription

1 Patient Name: Date of Study: Time to Arrive: Location: Phone: PREPARATION FOR ESOPHAGEAL MOTILITY STUDY 1. Have nothing to eat or drink for at least 6 hours before the exam. After the exam you may eat and drink normally. 2. Do not take your morning medications; however, bring them with you, as you will be able to take them after the exam. This is because certain medications may interfere with the test. You may take sublingual nitroglycerin as needed if this is one of your medications. 3. Bring a list of all your medications. 4. You will not be sedated for this procedure. 5. The exam will usually take 30 minutes 6. You will not need an escort. 7. Remember to bring your MGH identification card with you. If you do not have an identification card, please call the Registration Office at in advance or you can pick up the card in the Wang Ambulatory Care Center lobby, which opens at 7:30a.m. 8. If your insurance company requires a referral from your primary care physician or prior approval for this procedure, it is your responsibility to obtain this prior to the procedure. ESOPHAGEAL MANOMETRY Introduction Your doctor has scheduled an examination of the muscular function of your esophagus (esophageal motility) using a pressure sensing tube. Plead read this form so that you understand the procedure and the risks and benefits associated with it. Be sure to ask questions about anything on this form you do not understand. Procedure The esophageal manometry test measures the motor action and of muscles that are at the upper and lower ends of the esophagus, as well as the motor function of the esophageal body. It is performed using a catheter that senses pressure changes in the esophagus. A thin tube is passed through the nose into the stomach. The outer end of the tube attached to an instrument that will record the pressure. The tube is pulled slowly back into the esophagus and pressure measurements are taken at various intervals. The high- pressure zone of the lower esophageal sphincter muscle is recorded first. When the tube is in the esophagus, esophageal motor function is recorded during swallows. The motor function of the upper sphincter is then studied, after which the tube is removed. Benefits Esophageal motility testing provides clear documentation of the muscular function of the esophagus. With this information, your doctor can provide a specific treatment program as well as reassurance if the exam is normal. Risks The side-effects of esophageal manometry are minor and may include mild sore throat, temporary irritation of the nasal passages, and nose bleeds. Occasionally, during insertion, the tube may enter the larynx (voice box) and cause coughing. When this happens, the problem is recognized immediately, and the tube is rapidly removed. Alternatives to Manometry There are no other tests that provide precise information about esophageal motility. There are, however, other techniques that can provide general information about esophageal function. These are: upper GI x-ray series using swallowed liquid barium; video endoscopy to visualize the inside lining of the esophagus; and a 24-hour probe left in the end of the esophagus to measure acidity as it refluxes from the stomach. Last Updated: 11/14 Form: PP-ESMO-01

2 ESOPHAGEAL MANOMETRY, phz AND ph PHYSICIAN ASSESSMENT FORM Name: Date of Birth: / / Age: Physician: Referring Physician: Reason for Test: When was the last time you had something to drink? When was the last time you had something to eat? 1. Do you have trouble swallowing? YES NO (If the answer is NO skip to question 5) 2. How long have you had trouble swallowing? 3. If you have trouble swallowing please answer the following questions: How did the problem start? SUDDENLY GRADUALLY OVER TIME How often does it happen? ALL THE TIME SOMETIMES RARELY With solids? YES NO With liquids? YES NO 4. How would you describe your problem (check)? I have trouble when I start to swallow, getting the food to leave my mouth. PHYSICIAN FILE Food gets stuck after it leaves my mouth. 5. Do you have pain when you swallow? YES NO 6. Do you cough while eating? YES NO 7. Do liquids ever come back up into your nose while you are eating? YES NO 8. Please check the answer that applies to you for each of the following: Chest Pain: NEVER DAILY WEEKLY MONTHLY OTHER Heartburn: NEVER DAILY WEEKLY MONTHLY OTHER Antacid Use: NEVER DAILY WEEKLY MONTHLY OTHER Cough: NEVER DAILY WEEKLY MONTHLY OTHER (PLEASE TURN OVER) 2 of 4

3 Please check if you have a history of any of the following medical problems: Breathing problems Heart disease High blood pressure Bleeding disorders Strictures, fistulas, or obstructions in your gastrointestinal system Esophageal tumors, ulcers, or varices Deviated septum Nasal obstruction Hiatal hernia Please check if you have you had any of the following? Gastric surgery When Esophageal dilation When PHYSICIAN FILE Barium x-ray When Previous endoscopies When Please list any additional medical problems that you have: Please list any surgeries that you have had: Patient s Signature: Reviewed By: Date: Time: 3 of 4

4 MOTILITY PATIENT HOME MEDICATION FORM (PLEASE ONLY COMPLETE THIS SIDE OF FORM) Please list any medication allergies that you have: Do you have an allergy to latex? YES NO Please list all of your medications (include those that you stopped prior to this test): MEDICATION NAME DOSE FREQUENCY LAST TAKEN ORIGINAL PUT IN RN FILE, COPY PUT IN PHYSICIAN FILE Please sign below: Patient Signature: Reviewed by Nurses Signature: Date: / / Time: 4 of 4

5 Parking Information & Directions Blake Building, 4 th Floor 55 Fruit Street, Boston, MA Fruit Street Garage or Parkman Street Garage Garages are located off of Cambridge Street After parking in the Fruit Street -or- Parkman Street Garage Enter through the Main entrance Take the E elevator to the 4 th floor of the Blake Building Once you exit the elevator, look for the glass door labeled GI Associates Charles River Plaza, 9 th Floor 165 Cambridge Street, Boston, MA Our Charles River location has two options for parking: 1. Charles River Plaza Parking Garage, 207 Cambridge Street this is the preferred parking location 2. Fruit Street Garage -or- Parkman Street Garage From the Charles River Plaza Parking Garage (Preferred Parking Location) Look for the Orange wall labeled 165 Cambridge Street Take the elevator to the 9 th floor The entrance will be on your left From the Fruit Street / Parkman Street Garages Walk down North Grove Street, take a left onto Cambridge Street After walking 2 ½ blocks, you will see the sign for Charles River Plaza on your left The 165 Cambridge St. building will be on the right of the plaza - enter through the glass doors Elevators are at the end of the hallway, go to the 9 th floor - the entrance will be on your left Mass General / North Shore, Endicott Street, Danvers, MA Center for Outpatient Care parking lot Enter through the Main Entrance Elevators will be straight ahead For Procedures: Take the elevators to the 2 nd floor For Office Visits: Take the elevators to the 3 rd floor Please visit the MGH Parking Office website for more information and directions to our locations: Last Updated: 8/14 Form: DD-01