By : Kunkun Achmad MS

DEFINISI
The Montreal Definition :

A condition that
develops when the
reflux of stomach
contents causes
troublesome symptoms
and/or complications




Vakil N, et al. Am J Gastroenterol. 2006

GERD Pathophysiology :
3-Part Process
1) Decreased basal lower
esophageal sphincter (LES)
pressure
2) Decreased acid clearance
3) Refluxate of acid and pepsin
injures the esophageal mucosa
2 Groups of GERD
Erosive esophagitis
3-5% Asian countries (14-15% Taiwan and
Japan)
10-20% Western countries

Non-erosive Reflux Disease (NERD)
90% asian countries
70% Western countries




Fock KM et al. J Gastroenterol Hepatol 2008

Classic Symptoms
Heartburn

Regurgitation




Malfertheiner P, et al.Dig Dis. 2008;26(3):231-6
Atypical/Extra-esophageal
Manifestations
Atypical Extra-esophageal
Chest pain Oral - Pulmonary Chronic
Epigastric pain Dental erosion cough Asthma
Nausea Pharyngo-laryngeal Aspiration
Pulmonary
Pharyngitis/Laryngitis fibrosis
Hoarseness
Globus sensation - Other
Sore throat Sleep
abnormalities
Vocal cord polyps
Posterior laryngitis

Vakil N, et al. Z Gastroenterol.2007 Nov;45(11):1125-40
DIAGNOSTIC OF GERD
International Consensus
GERD is a symptom-based
diagnosis, and hence symptom
evaluation will remain the
primary means by which
treatment decisions are made
for patients with suspected
GERD


Hunt R, et al. Dis Esophagus.2009
Diagnostic Tests


Are we
losing sight
of the
symptoms ?
Tests to diagnose GERD
Proton pump inhibitor test (PPI Test)
Endoscopy
Ambulatory 24-hour esophageal pH
monitoring
Esophageal manometry
Radiography
Therapeutic Trial: a diagnostic tool
(?)
The use of a short course of
high dose PPI as a test in
diagnosing GERD

To achieve a significant
symptomatic improvement within a
short period of drug administration


Fass R, Hepato-Gastroenterol, 2001
THERAPEUTIC

MODALITIES
Treatment Options
Lifestyle modification
Medical treatment
Surgical treatment
Endoscopic treatment
Lifestyle Modifications
Avoid
Caffeine
Sodas * Fatty food
* Alcohol
* Smoking
* Citrus & tomatoes
* Spicy foods

Lifestyle Modifications
Avoid assuming
supine position for 3-4
hours after meals
Elevate head while
sleeping
Weight management
Avoid tightening your
belt or girldles
MEDICAL
MANAGEMENT

Acid-Suppression Therapy
H2RAs / H2 Blockers
* Ranitidine, famotidine, nizatidine,
and cimetidine
PPIs
* Omeprazole, esomeprazole,
lansoprazole, pantoprazole, and
rabeprazole
Acid suppression is the stronghold in
GERD management

Treatment Duration
4 8 weeks for Typical GERD

6 months for Atypical GERD (with
extra-esophageal manifestations)
RECURRENCE


May employ on-demand strategy of
treatment
Surgical Treatment
Antireflux surgery (Nissen/Toupet
fundoplication) is offered to patients in
the hope of obviating the need for
continuous medical therapy.
Positive predictors:
* good response to medical therapy
* less than 50 yrs old
* presence of typical GERD
symptoms