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98 187 1 SM
Correspondence mail:
Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia - Cipto Mangunkusumo Hospital.
Jl. Diponegoro 71, Jakarta 10430, Indonesia. email: pbpgi.jakarta@gmail.com.
ABSTRAK
Penyakit refluks gastroesofageal atau gastroesophageal reflux disease (GERD) merupakan suatu gangguan
dimana isi lambung mengalami refluks secara berulang ke dalam esofagus, yang menyebabkan terjadinya gejala
dan/atau komplikasi yang mengganggu. Berbagai penelitian epidemiologi menunjukkan adanya perbedaan
secara regional dari segi prevalensi dan manifestasi klinik. Data regional juga menunjukkan peningkatan angka
kejadian komplikasi seperti Barret’s Esophagus dan adenokarsinoma. Menanggapi situasi tersebut, pada tahun
2004, para ahli GERD di Asia Pasifik termasuk Indonesia telah mengeluarkan suatu konsensus bersama untuk
tatalaksana kelainan ini, kemudian direvisi pada tahun 2008.
Kemajuan teknologi kedokteran, khususnya teknik endoskopi gastrointestinal dan perangkat diagnostik lainnya
seperti pH-metri 24 jam dan manometri, telah meningkatkan kemampuan penatalaksanaan GERD. Di sisi lain,
pengetahuan dan kemampuan para dokter, baik dokter umum maupun spesialis penyakit dalam di negara kita
dalam penatalaksanaan GERD yang adekuat, dirasakan belum merata. Begitu pula penyediaan sarana penunjang
diagnostik dan terapeutik yang tidak sama antara satu daerah dengan yang lainnya. Pengurus Besar Perkumpulan
Gastroenterologi Indonesia (PB PGI) memandang perlu untuk merevisi Konsensus Nasional Penatalaksanaan
GERD di Indonesia tahun 2004, yang diharapkan akan menjadi suatu pedoman penatalaksanaan GERD.
ABSTRACT
Gastroesophageal reflux disease (GERD) is a disorder, which gastric content repeatedly reflux into the
esophagus causing disturbing symptoms and/or complications. Various epidemiological studies show that there
is regional difference on the aspect of prevalence and clinical manifestation. Regional data also demonstrates
increased incidence of complications such as the Barret’s Esophagus and adenocarcinoma. In response to the
situation, the Asia-Pacific GERD experts, including Indonesia, had published a consensus on the management
of GERD in 2004, which was subsequently revised in 2008.
Advances in medical technology, especially on gastrointestinal endoscopy technique and other diagnostic
instruments such as 24-hour pH-metry and manometry, have improved the capacity of management of GERD.
On the other hand, we feel that adequate knowledge and skills of doctors, both for general physicians and
specialists of internal medicine in our country are not well-distributed. Moreover, the availability of instruments
for diagnostic and therapeutical supports differs from one region to the others. The Organizing Committee of
Indonesian Society of Gastroenterology or Pengurus Besar Perkumpulan Gastroenterologi Indonesia (PB PGI)
considers that it is important to revise the National Consensus on the Management of GERD in Indonesia 2004,
which is expected to be the guideline of GERD management.
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which is also from RSCM/FKUI-Jakarta, the experts have agreed that both symptoms are
shows that of 1718 patients who underwent characteristics for GERD.1
upper gastrointestinal endoscopy on indication In a tertiary referral hospital, before performing
of dyspepsia for 5 years (1997-2002), there is endoscopic examination to establish the diagnosis
an increased prevalence of esophagitis, from of GERD, other further investigation (laboratory,
5.7% in 1997 to 25.18% in 2002 (mean value of ECG, USG, chest X-ray and other investigation
13.13% per year).7 in accordance with the indication) should be also
Some risk factors for GERD have been carried out to exclude diseases with symptoms
evaluated in Asia-Pacific population, including similar to the GERD. The Asia-Pacific experts have
elderly age, male, race, family history, high stated by acclamation that the regional strategy of
level of economic status, incrased body mass diagnostic GERD must consider the possibility
index and smoking. The strongest evidence is of GERD exists with other comorbidities such
provided for association of certain risk factors as gastric cancer and peptic ulcer. However,
wih the development of GERD in Asia-Pacific regarding the H. pylori test to exclude infection
population, i.e. the increased body mass index in patients with GERD symptoms in regions with
and more than 25 clinical studies have supported high prevalence of gastric cancer and peptic ulcer,
the correlation.8 there is a controversial opinion of the experts.
Nevertheless, the test is still recommended by
DIAGNOSIS considering risk factors including comorbidities,
Careful history taking is the main method age, histological profile of the stomach, family
to establish GERD diagnosis. Specific symptom history and patient’s preference.1
of GERD is heartburn and/or regurgitation GERD-Q
that occur after meal. However, it should be GERD Questionnaire (GERD-Q) (Table
emphasized that most of diagnostic studies 1) an instrument of questionnaire developed to
of heartburn and regurgitation symptoms are assist establishing the diagnosis of GERD and
performed in Caucasian population. In Asia, measuring response to therapy. The questionnaire
the symptoms of heartburn and regurgitation is developed based on clinical data and
are not the typical features for GERD. However, information obtained from high-quality clinical
Table 1. GERD-Q
Try to recall what you have experienced in the last 7 days.√
Put a check mark (√) only at one single space for each question and count your total GERD-Q score by doing summation
of the point(s) for each question.
Frequency of score (point) for symptoms
No. Question
0 day 1 day 2-3 days 4-7 days
How often do you experience the sensation of burning behind your
1. 0 1 2 3
breastbone / sternum (heartburn)?
How often do you experience the gastric content backing up into your
2. 0 1 2 3
throat / mouth (regurgitation)?
3. How often do you feel epigastric pain? 3 2 1 0
4. How often do you feel nauseated? 3 2 1 0
How often do you have difficulty to have night sleep due to the
5. burning sensation in the chest (heartburn) and/or the backing up of 0 1 2 3
abdominal content?
How often do you take additional medication for treating the
burning sensation in the chest (heartburn) and/or the backing up
6. of abdominal content (regurgitation), other than prescribed by your 0 1 2 3
doctor? (such as the over the counter drugs for treatment of stomach
complaints)
If your GERDQ points <7, you probably do
Result not have GERD. If your GERDQ points is
8-18, you probably have GERD
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studies as well as from qualitative interviews Endoscopy for GERD is not always
with patients in order to evaluate the simplicity of performed on the first visit since the diagnosis
filling up the questionnaire. GERD questionnaire of GERD can be made based on symptoms
is a combination of validated questionnaires used and/or empirical therapy. The roles of upper
in the DIAMOND study. Improved accuracy gastrointestinal endoscopy in establishing the
of diagnosis by combining several validated diagnosis of GERD are:
questionnaire will increase the sensitivity and • Confirming the presence and absence of
specificity of diagnosis.9,10 esophageal damages including erosion,
An analysis on more than 300 patients at a ulceration, stricture, Barret’s esophagus or
primary health care service demonstrates that malignancy, in addition to excluding other
GERD-Q may provide sensitivity and specificity upper gastrointestinal abnormalilties.
of 65% and 71%, which is similar to results • Evaluating the severity of mucosal break
obtained by gastroenterologists. Moreover, using modified Los Angeles classification
GERD-Q also shows the capacity to evaluate or Savarry-Miller classification.
relative impacts of GERD on patients’ life and • Biopsy specimens are taken when there
to provide assistance in selecting therapy.9 is a suspicion of Barret’s esophagus or
Table 1 is the GERD-Q that can be filled malignancy.
up by the patients themselves. For each Histopathological Examination
question, respondent should fill up according Histopathological examination as the
to the frequency of symptoms that they have diagnostic tool of GERD is essential to
experienced in a week. Score 8 or more is the determine the presence of metaplasia, dysplasia
recommended cut-off point to detect individuals or malignancy. No supporting evidence has
with high tendency to have GERD.10 GERD-Q been provided about whether biopsy specimen
has been validated in Indonesia. is needed in NERD cases. In the future, further
Upper Gastrointestinal (UGI) Endoscopy studies on the role of high-resolution (magnifying
Upper gastrointestinal endocopy (UGIE) is scope) endocopy in NERD cases are necessary.
considered the gold standard for establishing 24-hour pH-metry Test
the diagnosis GERD with erosive esophagitis.
The roles of conventional 24-hour pH-metry
Using the UGIE, we can find the mucosal break
test or 48-hour capsule (if available) in the
of esophagus. Endoscopy in GERD patients is
diagnosis of NERD are:13,14
mainly used for individuals with alarm symptoms
• Evaluating GERD patients who do not
(progressive dysphagia, odynophagia, weight
respose to PPI therapy.
loss with unexplained etiology, new onset of
• Evaluating whether the patients are those
anemia, hematemesis and/or melena, family
with extra-esophageal symptoms before the
history of gastric and/or esophageal malilgnancy,
PPI therapy or after failed PPI therapy.
chronic use of NSAID medication, individuals
• Confirming the diagnosis of GERD prior to
with age over 40 years in a region with high
anti-reflux surgery or evaluating symptoms
prevalence of gastric cancer) and for those who
of NERD repeatedly following the surgery.
do not response to empirical treatment using PPI
twice daily.1,11,12 PPI Test
While until now, there is no gold standard PPI test can be performed to establish the
for diagnosis of NERD. The following criteria diagnosis in patients with typical symptoms and
is used as the guideline for establishing the without alarm signs or risk for Barret’s esophagus.
diagnosis of NERD:1 The test is carried out by administering double-
• No mucosal break found in the upper dose PPI for 1-2 weeks without the preceding
gastrointestinal endoscopy, endoscopy examination. If the symptoms subside
• Positive results on esophageal pH test, with PPI administration and recur when the PPI
• Twice-daily empirical therapy with PPI gives treatment is stopped, then the diagnosis of GERD
positive response. can be made. The test is considered as positive
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The Indonesian Society of Gastroenterology Acta Med Indones-Indones J Intern Med
Antacids +1 0 0 0
Prokinetics +2 +1 0 +1
H2-receptor antagonists +2 +2 +1 +1
H2-receptor antagonists and
prokinetics +3 +3 +1 +1
High-dose H2-receptor
+3 +3 +2 +2
antagonists
PPI +4 +4 +3 +4
Surgery +4 +4 +3 +4
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- Endoscopy
- Radiology Persistent symptoms improved symptoms
- pH-metry
For NERD, initial treatment can be provided GERD, which is refractory to PPI therapy
by giving single dose PPI for 4-8 weeks. After (no response to PPI therapy of twice daily for 8
the clinical symptoms diminish, therapy can be weeks) must be confirmed by reevaluating the
followed with PPI on demand. The ‘on demand’ GERD diagnosis using endoscopy to confirm
treatment is suggested in order to maximize the presence of any esophagitis. If no esophagitis
gastric acid suppression, which is administered is found, the investigation is followed with pH-
in 30-60 minutes before breakfast.1,11 metry test.
Based on the results of pH-metry, we
can determine the dominant factor for reflux
Table 3. PPI dose for GERD treatment27,28 of gastric content, either by hyperacidity or
PPI types Single Dose Double dose pathological anatomy factors such as (SEB
Omeprazole 20 mg 20 mg twice daily disorder, hiatal hernia, etc). If the pH-metry
Pantoprazole 40 mg 40 mg twice daily demonstrates the domination of pathological
Lansoprazole 30 mg 30 mg twice daily anatomy factors and the clinical symptoms are
Esomeprazole 40 mg 40 mg twice daily still there, the diagnostic test using esophageal
Rabeprazole 20 mg 20 mg twice daily impedance and pH can be considered (Figure
3) to confirm the next therapeutical measure
(tertiary treatment measure).1,11
Table 4. GERD classification based on endoscopic Now, the treatment for non-acid reflux
results29 (NAR) is still developing. Studies on Baclofen (a
ERD GABA-B agonist) has provided promising results;
NERD
Grade A Grade B Grade C Grade D however, further data is needed to recommend
Mucosal Diameter Diameter Diameter Lesion the drug routinely. 30,31 The recommended
break (-) <5 mm, <5 mm, >5 mm, encircling treatment includes avoiding large and late meal,
single several single, the
maintain head up position until 3 hours after
No lesions, several lumen
mucosal colonized lesions the meal, reduced body weight and head-up tilt
damage sleeping. However, no study has confirmed that
such treatments are clinically significant.
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Esophageal impedance + pH
positive
negative positive mild acid reflux
acid reflux
Consider administering
HzRA before bedtime
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