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
TERIMA KASIH
