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Konsensus Gastro Esophageal Reflux

Disease (GERD)
Perkumpulan Gastroenterologi Indonesia
(PGI)


Dr. Tjahjadi Robert Tedjasaputra SpPD, KGEH, FINASIM
Jakarta 10 Mei 2014


Masalah:
Kasus & komplikasi meningkat
Perbedaan prevalensi & manifestasi klinis
Teknologi diagnostik
Kemampuan diagnosis & penatalaksanaan
Revisi konsensus
Definisi : Gangguan (kualitas hidup) akibat
refluk berulang isi lambung ke esofagus.
Gejala: Heartburn, Nyeri dada nonkardiak
Regurgitasi,
Disfagia,
Odinofagia
Tumpang tindih dengan dispepsia
Gejala THT, Saluran nafas, Gigi & mulut




! Patients do not reliably
interpret the word
heartburn
! For symptom evaluation, a
burning feeling rising from
the stomach or lower chest
up toward the neck is
more reliable than
heartburn
Carlsson et al. Scand J Gastroenterol. 1998;33:1023-1029.
From Vakil N et al. Am J Gastroenterol 2006;101:1900-20.


Epidemiologi:

Barat 10-20%, Asia 3-5 %, Jepang: 13-15 % , IND
13 %
usia lanjut, pria, ras, riwayat keluarga, ekonomi
tinggi, IMT tinggi, dan merokok.



Patofisiologi:

- Kontak refluksat & mukosa esofagus
- Penurunan resistensi esofagus
- Gangguan sensitifitas persepsi sentral/perifer
mukosa esofagus
- Potensi perusak: as. Lambung, pepsin, garam
empedu, ensim pankreas.


Peranan motilitas, Helicobacter pylori, peranan
kebiasaan/gaya hidup, dan hipersensitivitas
visceral.
H Pylori: Cag A positif
Kebiasaan hidup: Rokok & IMT, Alkohol & Psikis,
Obat2an : e.g. Bronkodilator
Peran motilitas: TLESR (Transien Lower
Esophageal Sphincter Relaxation), disfungsi
LES, bersihan esofagus & pengosongan
lambung.
Hipersensitifitas viceral: persepsi perifer &
sentral.

There is no single
diagnostic gold
standard for GERD

Diagnosis:

Anamnesis: GERD Q
Penunjang menyingkirkan diagnosis:
laboratorium, EKG, USG, foto toraks, dan
lainnya sesuai indikasi).

! Coronary artery disease
! Gallstones
! Gastric /esophageal cancer
! Peptic ulcer disease
! Esophageal motility disorders
! Pill induced esophagitis
! Eosinophilic esophagitis
From Kahrilas PJ. N Engl J Med 2008;359:1700-7.
! Empiric trial
! Barium esophagram
! Endoscopy
! Manometry
! pH testing
! Impedance
! GERD despite therapy
! Dysphagia
! Odynophagia
! GI bleeding/anemia
! Mass, stricture or ulcer on imaging
study
! Recurrent symptoms after antireflux
surgery
From Gastrointest Endosc 2007;66:219-24.
! Screening for Barretts in
selected patients
! Persistent vomiting
! Suspected extraesophageal
GERD
From Gastrointest Endosc 2007;66:219-24.
Pembagian endoskopis: ERD & NERD
GERD Refrakter: Tidak respon PPI 4-8
minggu
NAR (Non acid reflux): Cairan empedu/
asam lemah/alkali/ gas ! Manometri,
Impedans, Bilitec
Komplikasi: Barretts esophagus,
Adenocarcinoma
From Kahrilas PJ. N Engl J Med 2008;359:1700-7.
From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.
Reflux symptoms/mucosal breaks not visible in standard video
endoscopy
Pemeriksaan Penunjang
Endoskopi Saluran Cerna Atas: Magnifying
scope
Histopatologi
pH metri 24 jam
PPI Tes
Esofagogram
Manometri esofagus
Tes Impedans
Tes Bilitec
Tes Bernstein
Surveilance Barretts Esophagus

! Most accurate test for
measuring pattern, frequency,
and duration of reflux episodes
! Documents correlation between
reflux episodes and symptoms
! Sensitivity (77-100%)
Normal in 25% of esophagitis!
! Specificity 85-100%
! Most useful when diagnosis still
unclear
Dent et al. Gut. 1999;44(suppl 2):S1-S16.
From Smout A. Aliment Pharmacol Ther
2007;26(Suppl2):7-12.
! Considered to be the most sensitive test
for diagnosing reflux
! Traditional ! transnasal catheter with
probe situated 5 cm above LES
! Bravo pH system ! wireless technology
! PPI are standard medical therapy
Daily PPI generally has a 80% healing rate for
moderate to severe esophagitis and relief of
symptoms in up to 90% of patients
! Overall, all PPI are equally effective in
treating symptoms. However, there is
some variability in response from patient
to patient
! Proper timing of PPI administration is
critical for efficacy
! 30 minutes before breakfast or other
large meal
! In select patients, a second dose can be
added before the evening meal
! Indications
Esophagitis
Stricture
Barretts metaplasia
Medication failure
! Purpose of surgery ! restoration the LES

! In development with ongoing studies
! Most try to improve LES function in some
manner
! Not quite ready for prime time in
community practice
! Decrease in symptom
score
! Decreased PPI
! No effect on LESP
! No effect on acid
exposure
! Some serious thermal
injury complications
! Decreased heartburn symptoms
! PPI eliminated in 74% of patients at 6
months
! Decreased esophageal acid exposure;
however, only 30% completely
normalized
! Long term follow-up needed





TERIMA KASIH