12.GERD Dan Skoring Gerd-Q

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Transcript of 12.GERD Dan Skoring Gerd-Q

  • 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