SINDROMA SALURAN CERNA

ATAS

dr. Erwinsyah Sp.PD

 SINDROMA = kumpulan dari gejala simptomatik yang
timbul akibat satu atau lebih penyakit/gangguan
fungsi organ

 SALURAN CERNA ATAS= dimulai dari mulut---

ligamentum Treiz (duodenum)
Klasifikasi
 1.Dispepsia
- Dispepsia Fungsional
- Dispepsia organik

- 2.GERD
- 3. NERD
 DISPEPSI
DEFENISI

 Sindroma klinik yang di sebabkan oleh beberapa

penyakit saluran cerna bagian atas
 Rasa nyeri/sakit, dan dicomfort ulu hati,
bersifat eopisodik dan persisten, akut/kronis
fungsional dan organik.
 SIMPTOM DISPEPSIA
Sindrom yang dialami :
 Sakit Perut atas & Discomfort, rasa penuh setelah
makan (fullness), kembung (bloating), cepat
kenyang (early satiety), sendawa (belching),
kurang nafsu makan/anoreksia, muntah/vomiting,
mual/nausea, heart burn/pirosis dan regurgitasi
asam.
 Nyeri/sakit ulu hati, sakit tengah malam,
menyebar kepunggung.
 Terminologi lain : Non Ulcer, fungsional, X-ray (-),
esensial, flatulen, idiopatik dan epigastrik distress
dispepsi .
Dispepsia Fungsional 2-5 %  dokter keluarga
13,6 % pasien dokter umum
20-40 % konsultasi Gastroenterologi

DISPEPSIA

• Tipe dismotilitas
• Tipe tukak
• Non spesifik
• Refluks
PATOFISIOLOGI DNU / DF
* Multifaktorial disorder
* Dismotilitas lambung
Asam ?
Psikiis
Hipersensitivitas makanan, alkohol, kopi,
rokok, NSAIDs Infeksi HP
Helikobakter Pilori
* Tergantung pada : - agents
- Host
- Lingkungan
* Peranan pada DNU
perbedaan prevalensi HP
eradikasi HP menghilangkan simptom
DISPEPSIA FUNGSIONAL
* Prevalensi : USA 25%
Skotlandia 25%
Denmark 34%
Inggris 41%
Karena pengelompokkan gejala dispepsia tidak
berhubungan dengan patofisiologi

maka penatalaksanaan berdasarkan gejala yang

predominan
 Dispepsia abad 21 ( Milenium III )

1900

2000 Kanker Tukak DF GERD

Lambung Peptik
 DISPEPSIA FUNGSIONAL th 2000 (MILLENIUM III)
* Berbeda dan overlapping dengan GERD & IBS
* 2 sub group utama
sakit ulcer like
Discomport dismotility like

PERBEDAAN DEMOGRAFI DARI SUBGRUP

DISPEPSIA
Prev. sakit Prev. discomfort
Seks 69 % (M) 60 % (F)
Umur rata-rata 41 tahun 39 tahun
BB > ideal < ideal
Overlap. GERD 24 % 23 %
Overlap. IBS 12 % 30 %
GET normal delayed
%-delayed 11 % 42 %
 Penyebab Dispepsia Kronis
Penyakit Evaluasai Klinis

NUD/DF Umur muda, alarm (-)

Tukak Peptik kronik NSAIDs, Serologi HP (+), rokok,
PSCA, anemia.
GERD Heart burn, Refluks asam
Kanker Lambung Umur tua, alarm (+), BB , HP(+)

Misscelanous

Peny.Bilier/sal Kolik Bilier

Pankreatitis kronik
Angina Intestinal
Obat-obatan
Nyeri menetap radiasi kepunggung,
alkohol, DM.
Sakit post prandial, takut makan,
BB turun, rokok, DM,komplikasi DM
Teofilin, besi, K, digoksin, Antibiotik.
 DAERAH DENGAN
“ TINGGI KANKER RATE”
Dispepsi tidak terinvestigasi

Simptom alarm

(+) (-)

Endoskopi HP (+) HP (-)

Terapi tepat / Empiris, prokinetik

eradikasi, empiris / antisekretorik
 DAERAH DENGAN
“ RENDAH KANKER RATE”
Dispepsi tidak terinvestigasi

Simptom alarm

(+) (-)

Endoskopi HP (+) HP (-)

Terapi tepat / Terapi Empiris,

eradikasi, HP prokinetik /
empiris antisekretorik
 Langkah awal penatalaksanaan
dispepsia dalam praktek

. Latar belakang masalah

80 % pasien tanpa kelainan organik
. Sebelum menetapkan terapi :
1. Singkirkan peny. Non GI, bilier, IBS,
refluks
2. Keluhan < 2 – 4 minggu : diet
makanan lembek, makan teratur,
jangan terlalu banyak, faktor
pencetus makanan tertentu hindari,
tidak merangsang / pedas, asam,
lemak, alkohol, kopi, rokok  Terapi
di evaluasi
3. Waspadai “alarm simptom”, (+)
 endoskopi (disfagia, perdarahan,
anemia, BB  ? Simptom dispepsia
berat, awal dispepsi > 45
4. Singkirkan obat-obat NSAIDs,
analgetik
5. DF banyak diklinik, kemungkinan
seumur hidup, “ patients – physician
relationship” yang baik.
6. First line treatment antasid,
prokinetik,PPI/ARH2
Bila gagal  kombinasi terapi
atau periksa
HP/lokal  bila (+)  eradikasi
Definition:
 GERD
“….thepresence of typical symptoms of GERD
caused by pathological reflux of
intraoesophageal acid, ranging from simple to
erosive to Barrett’s.”

 NERD (Non-erosive reflux disease)

Reflux disease in which erosion does not
occur
Range of presentation of GERD
Typical symptoms
(Heartburn/regurgitation)

With
oesophagitis

Without
oesophagitis
 Range of presentation of
GERD
Atypical symptoms Complications

Chest pain Oesophageal

(visceral erosions
hyperalgesia) and/or ulcers

Hoarseness Stricture
(‘reflux
laryngitis’)

Asthma, Barrett’s
chronic cough, oesophagus
wheezing

Dental erosions Oesophageal

adenocarcinoma

Nathoo, Int J Clin Pract 2001; 55: 465–9.

 GERD
Erosive
30%

Nonerosive
70%
 Los Angeles classification
system for oesophagitis
Grade A
One or more mucosal
breaks, no longer than
5 mm, that do not extend
between the tops of two
mucosal folds
Grade C
One or more mucosal
breaks, that are continuous
between the tops of two or
more mucosal folds, but
which involve less than 75%
of the circumference
Grade B
One or more mucosal
breaks, more than 5 mm
long, that do not extend
between the tops of two
mucosal folds
Grade D
One or more mucosal
breaks, that involve at
least 75% of
the oesophageal
circumference
Lundell et al., Gut 1999; 45: 172–80.
Progression of GERD

•Most do not progress over time

•Not at risk of developing Barrett’s
oesophagus
•If there is progression, usually to low
grades of erosive oesophagitis
Goals of Treatment in GERD
 Provide satisfactory acute and long term symptom control

 Prevent symptom relapse

 Improve patients’ health-related quality of life

 Reduce reliance on antireflux treatment modalities

 GERD Treatment Options

Lifestyle Antacids and

modifications alginates

PPIs Approaches H2RAs

Prokinetic motility Surgery

agents
 Lifestyle Modifications

Reduce weight

Stop smoking Elevate head

of bed

Modifications

Avoid reflux-promoting Eat small meals,

agents (e.g. alcohol, no late meals, reduce
coffee, some foods) fat
(not evidence based)
Antacids
Increases pH of refluxate
Quick relief of mild symptoms
Less effective than PPIs or H2RA
Adverse effects-diarrhoea,
constipation,accumulation in renal failure
Prokinetic Agents
 Increase LOS and enhance gastric emptying

 Relieve heartburn but not heal oesophagitis

 GERD Treatment

REMISSION

MAINTENANCE

Continuous Rx Intermittent Rx On demand Rx

Continuous PPI therapy

vs

On-demand PPI therapy

Definitions
INTERMITTENT Rx
Physician driven
Short, predetermined courses of therapy
when sx occur (1-2 weeks duration)
Duration fixed by physician
ON DEMAND Rx
Patient driven
Patient consumes therapy
when and during periods
that patients desire
 Patients in control
Convenient

ADVANTAGES OF
ON-DEMAND PPI Rx

Reduced cost to Decrease in the

patients & health providers rebound of acid secretion
Available PPIs
Lansoprazole
Omeprazole
Esomeprazole
Pantoprazole
Rabeprazole

BUT ARE THEY ALL THE SAME?

Choosing a PPI

 Rapid onset of action

 Long duration of effect

 Stable effect independent of drug-drug interactions

 Predictable therapeutic response

 Low risk of adverse events

Who is eligible for on demand PPI?
Suitable candidates
 Symptomatic, nonerosive GERD: up to 70%
of GERD
 Mild to moderate erosive oesophagitis:70-
85% of erosive oesophagitis patients

Patients who should not use on

demand PPI Rx
 Severe erosive oesophagitis
 GERD complications (strictures, Barrett’s)
 Extraoesophageal manifestations of GERD