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