Dyspepsia & GERD

of 65

  • date post

    02-Apr-2018
  • Category

    Documents

  • view

    213
  • download

    0

Embed Size (px)

Transcript of Dyspepsia & GERD

  • 7/27/2019 Dyspepsia & GERD

    1/65

    Erwin Budi Cahyono

  • 7/27/2019 Dyspepsia & GERD

    2/65

    DEFINITION :

    Symptoms like pain or nausea in epigastrium

    accompanied by disgust, vomit, bloat, easy tofull, fullness or nitre, which is suspected comefrom the abnormality of upper gastro-intestinal tractus.

  • 7/27/2019 Dyspepsia & GERD

    3/65

    Dysmotility

    H. pylo r iinfection/

    inflammation

    Psychosocial

    factors

    Altered gastric

    acid secretion

    Gut hypersensitivity

    Mechanisms of

    dyspepsia

    Witteman & Tytgat, Netherlands J Med1995; 46: 20511.

    Talley et al., BMJ2001; 323:12947.Tack et al., Curr Gastroenterol Rep 2001; 3: 5038.

    Dyspepsia:

    pathogenic mechanisms

  • 7/27/2019 Dyspepsia & GERD

    4/65

    Nature of symptoms

    Patients degree

    of distress

    Severity of

    symptoms

    Alarm features

    Assessment

    of symptoms

    Character

    Radiation

    Timing, duration

    and frequency

    Modifying factors

    Par, Can J Gastroenterol1999; 13: 64754.

    Dyspepsia:

    symptom assessment

  • 7/27/2019 Dyspepsia & GERD

    5/65

    acute dyspepsia (new onset dyspepsia) Suddenly sigh with the quality of sigh which is

    usually more tremendous with a longer response tothe medication.

    chronic dyspepsia Sigh which is sometimes disappear, sometimes

    appear, more than two weeks. The sigh is not astremendous as acute dyspepsia with a quick

    response to the medication.

  • 7/27/2019 Dyspepsia & GERD

    6/65

    Organic Dyspepsia :

    There is an organ abnormality as ulcer gastro-

    duodenal, gastro esofageal reflux and gastriccarcinoma (Talley, 1998)

  • 7/27/2019 Dyspepsia & GERD

    7/65

    A common term which is given to the patient as :

    abdominal pain or nausea on the upper of stomach

    which is repeatedly happen more than three months,

    and at least a long of that time 25% symptoms ofdyspepsia appear and no evidence organic disease

    which is responsible to that symptoms clinically,

    biochemistrically, endoscopy and ultrasonografy

    (Talley et al, 1991). But, patient with gastritis and

    duodenitis non erosif is included in this term (Hu &

    Kren, 1998)

  • 7/27/2019 Dyspepsia & GERD

    8/65

    Functional Dyspepsia

    At least 3 months, with onset at least 6 months previously,

    of 1 or more of the following:

    Bothersome postprandial fullness Early satiation

    Epigastric pain

    Epigastric burning

    And

    No evidence of structural disease (including at upper

    endoscopy) that is likely to explain the symptoms

  • 7/27/2019 Dyspepsia & GERD

    9/65

    Epigastric Pain Syndrome

    At least 3 months, with onset at least 6 months previously, with ALL of

    the following:

    Pain and burning that is:

    intermittent

    localized to the epigastrium of at least moderate severity, at least once

    per week,

    and NOT:

    generalized or localized to other abdominal or chest regions2. relieved by defecation or flatulence

    3. fulfilling criteria for gallbladder or sphincter of Oddi disorders

  • 7/27/2019 Dyspepsia & GERD

    10/65

    Postprandial Distress Syndrome

    At least 3 months, with onset at least 6 months

    previously, of 1 or more of the following:

    Bothersome postprandial fullness

    1. occurring after ordinary-sized meals

    2. at least several times a week

    Early satiation

    1. that prevents finishing a regular meal

    2. and occurs at least several times a week

  • 7/27/2019 Dyspepsia & GERD

    11/65

    GASTRITIS

    - Peradangan mukosa lambung (Dx PA)- Gastroskopi: eritema, edema, erosiva

    - Klinik: keluhan dispepsia

    Sering dijumpai dalam klinik:- Gastritis antrum, Gastritis erosiva,

    - Gastritis hemoragika, Gastritis atropik, Penyebab:

    - infeksi Helicobacter pylori, OAINS,- refluks empedu, obat lain, stress, alkohol

  • 7/27/2019 Dyspepsia & GERD

    12/65

    ULKUS PEPTIK

    Ulkus Peptik- Kerusakan (luka) mukosa, besar (> 5mm)

    dan dalam (> submukosa), sifat jinak- Gastroskopi: bentuk ulkus- Klinik: keluhan dispepsia

    Pembagian berdasarkan lokasi kelainan:- Ulkus Esofagus- Ulkus Gaster- Ulkus Duodenum

  • 7/27/2019 Dyspepsia & GERD

    13/65

    * Sindroma Dispepsia

    * Komplikasi : muntah, muntah/berak darah, nyeri hebat.

    1. Keluhan / gejala

    2. Tanda fisik

    * Tidak jelas, nyeri tekan uluhati (hebatkomplikasi)

    3. Radiologi (foto seri SCBA)

    * Kontras tunggal akurasi rendah, sebaiknya kontr as ganda

    * Gastr i tis (edema, hipersekresi), Ulkus (niche/ kawah ulkus)4. Gastroskopi

    * Diagnosis utama, akurasi >95%,

    * Dx. endoskopi, biopsi (PA, CLO, dll .)

  • 7/27/2019 Dyspepsia & GERD

    14/65

  • 7/27/2019 Dyspepsia & GERD

    15/65

    Multiple causes of gastritis/ peptic ulcer disease

    Defensive

    Aggressive

    Gastric lumen

    Mechanical stressChemicalIrritant (Alcohol, NSAIDs)Pepsin, Acid

    H+

    Pepsin, Acid

    Solubilized mucus

    H+

    back

    diffusion

    Surface mucus

    cell

    Parietal

    cell

    Gland-type mucuscellChief cellShay & Suns

    balance theory

  • 7/27/2019 Dyspepsia & GERD

    16/65

    Agressive Factors Gastric Acid

    Pepsin Refluxs bile

    Nicotin

    Alcohol

    Antiinflamation nonsteroidmedicine

    Cortikosteroid

    Helicobacter pylo r i Free radical

    Agresif Factor Defensif Factor

    Defensive Factors

    Mucosa blood current

    (microsirculation)Superficial epithel cell

    Prostaglandin

    Fosfolipid/Surfactans

    Musin

    Bikarbonat

    Motilitas

    Diagram of the equlibrium theory of integration gastro-intestinal

    tractus mucosa especially gastric & duodenum

  • 7/27/2019 Dyspepsia & GERD

    17/65

    Surface epithelialcells

    Mucus layer

    Ionic gradientBicarbonate layer

    Prostaglandins

    Mucosal bloodsupply

    NSAIDs

    H . pyloriPepsinGastric

    acid

    Acidicenvironment

    Neutral environment

    Bile

    AGGRESSIVE FACTORS

    PROTECTIVE FACTORS

    Imbalanced between aggressive factors and protective factors

    Noxious agents

    Pre-epithelial

    Epithelial

    Sub-epithelial

  • 7/27/2019 Dyspepsia & GERD

    18/65

  • 7/27/2019 Dyspepsia & GERD

    19/65

  • 7/27/2019 Dyspepsia & GERD

    20/65

  • 7/27/2019 Dyspepsia & GERD

    21/65

  • 7/27/2019 Dyspepsia & GERD

    22/65

  • 7/27/2019 Dyspepsia & GERD

    23/65

  • 7/27/2019 Dyspepsia & GERD

    24/65

  • 7/27/2019 Dyspepsia & GERD

    25/65

    H.Pylori cover, T.L., et al. :ASM Nwes, 61(!),21,1995

    H.Pyloriinfection

    MALT

    Lymphoma

    Chronic

    SuperficialGastritis

    Peptic

    Ulcer Disease

    Chronic Superficial Gastritis

    (Histological Gastritis)

    Gastric Cancer

    Chronic

    Atrophic

    Gastritis

  • 7/27/2019 Dyspepsia & GERD

    26/65

    Proposed natural history ofHelicobacter

    pyloriinfection in humans

    Childhood Old Age

    Chronic Active GastritisAcuteGastritis

    Environmental

    Factors

    MultifocalAtrophic

    Gastritis

    AntralPredominantGastritis

    Gastric Cancer

    Lymphoma

    Gastric Ulcer

    Duodenal Ulcer

    Duodenitis

    H.pylor i

  • 7/27/2019 Dyspepsia & GERD

    27/65

    Test Sensitivity/specifity, % Comments

    INVASIVE (ENDOSCOPY/BIOPSY REQUIRED)

    Rapid urease

    Histology

    Culture

    80 - 95/95 100

    80 90/>95

    --/--

    Simple, false negative with recent use of PPIs,

    antibiotics, or bismuth compounds

    Requires pathology processing and informationTime-consuming, expensive, dependent on

    experience; allows determination of antibiotic

    susceptibility

    NON-INVASIVE

    Serology

    Urea breath test

    Stool antigen

    >80/>90

    >90/>90

    >90/>90

    Inexpensive, convenient; not useful for early

    follow-up

    Simple, rapid; useful for early follow-up; false

    negatives with recent therapy (see rapid urease

    test); exposure to low-dose radiation with 14C test

    Inexpensive, convenient; not established for

    eradication but promising

  • 7/27/2019 Dyspepsia & GERD

    28/65

    Normal

    mucosa

    Superficial

    gastritis

    Atrophic

    gastritis

    Intestinal

    metaplasiaDysplasia Gastric

    adenoCa.

    Salt Higher pH

    Salt

    N-nitroso carcinogensInflammatory cell carcinogens

    Ascorbic acid -carotene H. pylo r i

    Chronic atrophic gastritis Gastric ulcer Gastric adenoma with dysplasia Gastric cancer

  • 7/27/2019 Dyspepsia & GERD

    29/65

  • 7/27/2019 Dyspepsia & GERD

    30/65

  • 7/27/2019 Dyspepsia & GERD

    31/65

    1. Menghilangkan keluhan

    2. Mempercepat penyembuhan luka

    3. Mengobati komplikasi

    4. Mencegah kekambuhan

  • 7/27/2019 Dyspepsia & GERD

    32/65

    Penting mencari:

    - faktor-2 yang berperan pada penyakit

    - diagnosis dan pengobatan yang sesuai

    2. Merubah cara hidup (life style)

    Faktor yang perlu diperbaiki a.l.:

    - rokok, alkohol, diet, cara makan, dll.

    - stress psiko-sosial