ActiveMime 3+hJD' = @B D' = @BA?%,( < +O%,( < +D ' =%(%(D' =%(D9' =4@BBBB%( D' =1:Bvisible*o3>+B#style.visibility<*%(D' =-u6Bwipe(right)*<3<*+0+)D' = @B De' = @BA?%,( < +O%,( < +D' =%(%(D' =%(D3' =4@BBBB%(D' =1:Bvisible*o3>+B#style.visibility<* %(D' =-o6Bwipe(up)*<3<* D' =%( D9' =4@BBBB%( D' =1:Bvisible*o3>+B#style.visibility<* %(D' =-u6Bwipe(right)*<3<* +@.@mP.@h(`f.N0Department of PediatricsDiscuss terminology OTC vs prescription First on the market Generic vs brand Liquid vs tablets vs capsules DoP. !K .@/SwpH.@0Department of PediatricsWhy talk about acid-blockers and PPI's in particular Bacterial overgwoth demonstrated in the elderly DoP. $$  .0Department of Pediatrics:Pancreatic replacement enzymes are broken down by gastric acid. By decreasing the acid you increase the amount of active enzyme that reaches the small bowel. DoP. &6 +D=' = @B +].0Department of PediatricsGI Sx very common in CF. Prevalence of GER in CF probably nearer 50%. DoP. ' +D=' = @B +.0Department of PediatricsBTwo factors that contribute to how harmful reflux is for you. First is how often it occurs. This depends on factors such as: Decreased resistance: low tone of LES, or inappropriate relaxation (most common cause of GER in non-CF patients), inadequate support such as a hiatal hernia. Increased volume: large meals or poor motility that can result in delayed gastric emptying or even reflux back from small bowel into stomach Increased pressure: tight clothing, coughing, straining, sneezing, wheezing any increased work of breathing. DoP. /*(+D=' = @B +3.0Department of Pediatrics`What influences how long the relux hangs around? DoP. -1 +D=' = @B +.@0Department of Pediatricsreflux can cause problems in any place that if reaches such as nasopharynx - sinuses upper airway - hoarseness & cough lower airway - cough, asthma, pneumonia External - loss of calories esophagus - heartburn, bleeding, cancer DoP. 4" +D=' = @B +Y+D=' = @B +Y+D=' = @B +.0Department of PediatricsThis slide is to show you how powerful acid-blocking medicines are. Look at the middle area. Noraml pH in the stomach is less than 4. normally pH is greater than 4 only for a few hours a day ( with meals) with twice daily dosing of an H2 blocker such as Zantac ph is >4 for about 6 hrs a day, with ONCE daily dosing of a PPI the pH is > 4 for more than double that time, about 14 hrs a day. DoP. ; +D=' = @B +.0Department of PediatricsXWe don't always think to look for other causes of GI discomfort and poor weight gain such as bacterial over growth. When people have looked they found it was pretty common. DoP.  & .0Department of PediatricsDSx are vague Bacteria use up calories and prevent normal digestion. the by products of bacteria irritate the bowel causing inflammation which may cause bleeding. DoP.  * .0Department of PediatricsVAt ph 4.0 (noraml stamch acid levels bacteria are killed inabout 15 minutes. Stomcah acid denatures protein and starts the process of digestion, particulary of protein. DoP.  i .5Z0y.0Department of PediatricsWe know that PI CF patients have slow motility in the gut - constipation, DIOS - shown in studies. Moucous is thick and this is where bacteria live. pacreatic secretions also have anitbacterail properties. DoP.   +D=' = @B +@i.Ζv+D=' = @B +P.t0Department of PediatricsBreath test involves coming to Stanford in the morning before you eat breakfast, you have to drink a sugary drink and then we collect samples as you breathe out at intervals over about 2 1/2 hours. than you go home. The test may cause gas and mild diarrhea. DoP.  "" +D=' = @B +`Y+D=' = @B +p.Ѐi .H0Department of Pediatrics. 6.Є 0.0N.0. .PD%.K.@.߼.p׽ .@RH0.r@.4P.P 4Vx