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 Barrett s 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 Barrett s 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
! 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 Barrett s 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
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