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

!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