Anda di halaman 1dari 37

Diagnosis and treatment of

GERD
GERD DEFINITION

a condition which develops when


the reflux of stomach contents
causes troublesome symptoms
and/or complications.

Montreal definition of
GERD 2006
Pathophysiology of GERD

salivary HCO3
Impaired oesophageal
mucosal
defence clearance of acid
(lying flat, alcohol,
coffee)
Impaired LOS
(smoking, fat, alcohol) Hiatus hernia
transient LOS
relaxations acid output
H+ (smoking, coffee)
basal tone Bile and pancreatic Pepsin
enzymes
intragastric pressure
(obesity, lying flat)

bile reflux gastric emptying (fat)

de Caestecker, BMJ 2001; 323:7369.


Johanson, Am J Med 2000; 108(Suppl 4A): S99103.
Whats NERD?
(Non Erosive Reflux diseases )

Non-erosive reflux disease (NERD ) is defined by the


presence of troublesome reflux-associated symptoms
and the absence of mucosal breaks.

NERD is the mayority of patients with GERD (70-80% )


(Vakil et al. Am J Gastroenterol 2006;101:1900-1920)
Range of Clinical presentations of GERD

Typicalsymptoms
Atypical Complications
(Heartburn/regurgitation)
symptoms

With Chest pain Oesophageal


erosions
oesophagitis (visceral and/or ulcers
hyperalgesia)
Without Hoarseness Stricture
oesophagitis (reflux
laryngitis)

Asthma, Barretts
chronic oesophagus
cough,
Nathoo, Int J Clin Pract wheezing
Dental erosions Oesophageal
2001; 55: 4659. adenocarcinoma
Most common GERD symptom in Asia
Typical
Acid regurgitation - 87%
Feeling of acidity in the stomach - 45%
Angina-like chest pain - 35%
Heartburn - 30%
Dyspepsia - 29%
Dysphagia - 6.5%

Atypical
NCCP -
14.5%
Chronic cough - 13%
Laryngeal disorder - 10%
Asthma - 4.8%
Wong BCY et al. Aliment Pharmacol Ther. 2003
Clinical approach in the management
of GERD
Symptom base diagnosis
Exclusion of organic diseases
Esophageal Alarm symptoms
Extra Esophageal origin of symptoms
Chest pain : Cardiology work up, TMT, Echo
Pulmonary, pleuritic pain ; CXR
Empiric Treatment / PPI test 1 2 weeks
Initial Treatment 4 12 weeks
Long term treatment
Continuous for LA class D reflux Esophagitis
On Demand for NERD
GERD Diagnosis:
Based on typical symptoms alone or
Proton Pump Inhibitor (PPI ) test or
Tests demonstrating reflux of stomach contents ( pH
testing, impedance monitoring) or
the injurious effects of the refluxate (endoscopy,
histology, electron microscopy)

in the presence of typical or atypical symptoms


or complications.
Diagnostic tests for gastro-esophageal reflux disease

Tests to assess symptoms Tests to assess mucosal damage


Questioner ( GERD Q ) Endoscopy
Empirical trial of PPIs Esophageal mucosal biopsy
Intraesophageal pH monitoring with Barium esophagram
symptom analysis (SAP)

Tests for reflux Tests to assess esophageal


Intraesophageal pH monitoring function
Ambulatory bilirubin monitoring (bile Esophageal manometry
reflux) Esophageal impedance
Ambulatory impedance and pH Barium esophagram with
monitoring (non-acid reflux) fluoroscopy
Barium esophagram
GERD Diagnosis , Symptom base,
How accurate ?

Typical symptoms

Questioner : Diagnosis, Impact, monitoring

Symptoms response : PPI test


GERD, Symptoms base Diagnosis

GERD can be diagnosed based on symptoms alone. When


symptoms related to gastroesophageal reflux become
troublesome and affect a patients well-being, then that
patient has GERD. Symptoms that are not troublesome should
not be diagnosed as GERD.

Patient to define whether their reflux symptoms are


troublesome
Troublesome symptoms are defined by the
patient
to affect their quality of life

Mild symptoms occurring 2 or more days per week


or moderate to severe symptoms occurring more than 1
day per week are often considered troublesome by
patients

Not trouble some = episodic Heartburn


GERD
Heart burn ,What it is?
a burning feeling, rising from the stomach or
lower chest and
radiating toward the neck, throat, and
occasionally, the back
Occurs postprandially, particularly after large
meals or after eating spicy foods, citrus
products, fats, chocolates, or drinking alcohol.
GERD Diagnosis , Symptom base,
How accurate ?

Typical symptoms

Questioner : Diagnosis, Impact, monitoring

Symptoms response : PPI test


Diagnosis of GERD in Asia (2004)

Heartburn is NOT a word


understood in Asia
A burning feeling rising from the
stomach or lower chest towards
the neck
GerdQ ( Indonesian Version )
Combination of validated GERD questionnaires in DIAMOND
Study
Original GerdQ had been translated to Indonesia and already
validated in Indonesian language speaking - GERD patients at
VIRGINIA Study
GerdQ consist of 6 questions:
Symptom (4 questions)
Impact (2 questions)
Easy to use
Four scale answer
0 day 1 day 2-3 days 4-7 days

Jones RH , et al. Aliment Pharmacol Ther. 2009; 30: 10301038


18
Distribusi Skor GerdQ VIRGINIA Study

Cut off

93% pasien refluks


esofagitis skor > 7

Rani, A., Simadibrata M, Djumhana A, et al. Virginia Study. 2009


19
Scoring of GerdQ
A+B+C+D+E+F

Score GerdQ Assesment

0-7 Not GERD/ Low


likelihood of GERD

8-18 High likelihood of GERD


/GERD

20
Jones R et al. Aliment Pharmacol Ther 2009;30: 10301038 20
GERD Diagnosis , Symptom base,
How accurate ?

Typical symptoms

Questioner : Diagnosis, Impact, monitoring

Symptoms response : PPI test


When should you consider
endoscopy?

Alarm Symptoms
Dysphagia
Bleeding
Weight loss
Those that have marginal improvement in
symptoms with acid suppression therapy
including failure with a (PPI)proton pump
inhibitor.
Complications : Barretts, Stricture
Endoscopic oesophagitis is absent in the majority of
people with reflux disease

No erosions
57% Mild
Moderate
Severe
4%
30%
9%

Endoscopic findings
Severe reflux esophagitis. A, Mucosal erythema and linear ulcers with yellow exudates
(asterisks). B,It is thought that such changes eventually lead to Barrett's esophagus, in
which the normal white squamous epithelium (SE) is replaced by red columnar
epithelium (BE).
Neoplastic lesions in Barretts esophagus shown with high-resolution white light
(AC)

Corresponding images with narrow band imaging (DF). Surface relief is better
appreciated with narrow band imaging, which might aid in detecting more subtle
lesions (E, F) or delineating them for endoscopic resection (D).
Goals in the management
of GERD
Complete relief from heartburn and other symptoms.
Heal underlying esophagitis.
Maintain symptomatic and endoscopic remission.
Treat or prevent complications.

Achieving these treatment goals significantly


improves patient quality of life.
Control of acid secretion is the most effective
means to achieve these treatment goals.

Dent et al 1999
The best response to PPI treatment was found in patients with positive
SAP and pathological reflux. Subjects with a positive SAP and
physiological reflux responded less favorably, presumably reflecting
the element of visceral hypersensitivity in these patients.
Aanen CM et al 2006
Reduction in Heartburn Score
after a Single Dose in NERD

Placebo Rabeprazole 10 mg Rabeprazole 20 mg


Heartburn Score

3
Mean Daytime

2
* *
*
1

0
Baseline Day 1 Day 2
Heartburn Score

2
Mean Nighttime



1 * *

0
Baseline Night 1 Night 2

p<0.01, * p<0.001 Miner P et al. Gastroenterology 2000;118:A19


PPI symptoms relief during the first
week
Proportion of patients with Severe or Very Severe
heartburn during the first week of treatment
20
Daytime heartburn
15
Rabeprazole
20mg/day
% of patients reporting
10 Omeprazole 40mg/day
severe or very severe
heartburn * p<0.05
5
* *
0
1 2 3 4 5 6 7 Day
20
Nighttime heartburn
15
% of patients reporting Rabeprazole
20mg/day
severe or very severe
10 Omeprazole40mg/day
heartburn * p<0.05
*
5

0
1 2 3 4 5 6 7 Day

Holtmann G et al. Aliment Pharmacol Ther 2002;16: 479-485


NERD Patients Respond to
Rabeprazole than Esomeprazole
Time to the first 24-hr heartburn free
No. of patients who
1.00 experienced 24-hr
symptom free
Cumulative Rate of Symptom Free

84.4%

60.9%

0.50

Pariet
Nexium

0.00
0 7 14 21 28 Days

Fock KM. APDW Singapore 2003


NERD PATIENTS IN ASIA RESPOND
BETTER TO PPI

Fock 2005
Miner 2002
Goals in the management
of GERD
Complete relief from heartburn and other symptoms.
Heal underlying esophagitis.
Maintain symptomatic and endoscopic remission.
Treat or prevent complications.

Achieving these treatment goals significantly


improves patient quality of life.
Control of acid secretion is the most effective
means to achieve these treatment goals.

Dent et al 1999
Rabeprazole is effective in preventing
relapse of erosive or ulcerative GERD and is
well tolerated in a five-year maintenance
treatment

* P < 0.001 for rabeprazole vs placebo


* P = 0.005 for rabeprazole 20 mg vs 10 mg

N = 497 Caos A et al. Aliment Pharmacol Ther 2005; 22 (3): 193 - 202
What to do in treatment failure?
Adequate PPI dosage and administration
BID instead of OD
Higher dosage
Before meal
Change PPI (genetic polymorphism )
Rabeprazole
Confirm GERD diagnosis
pH monitoring, intra gastric, intra esophageal
Impendance monitoring for weak or non-acidic reflux
Therapeutic Modalities in PPI Failure

Failure of PPI once daily


Think Functional heartburn

Switch to another PPI

Double the PPI dose


Kesimpulan
GERD menjadi penyakit yang sangat banyak
dijumpai saat ini
Dibutuhkan ketepatan diagnosis dalam
membantu penanganan GERD
Dibutuhkan penanganan yang tepat dan cepat
dalam penanganan GERD
Rabeprazole bisa menjadi salah satu pilihan
PPI terbaik dalam penanganan GERD