12.GERD Dan Skoring Gerd-Q
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Transcript of 12.GERD Dan Skoring Gerd-Q
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Konsensus Gastro Esophageal Reflux Disease (GERD)
Perkumpulan Gastroenterologi Indonesia (PGI)
Dr. Tjahjadi Robert Tedjasaputra SpPD, KGEH, FINASIM Jakarta 10 Mei 2014
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Masalah:
Kasus & komplikasi meningkat Perbedaan prevalensi & manifestasi klinis
Teknologi diagnostik Kemampuan diagnosis & penatalaksanaan
Revisi konsensus
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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
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!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.
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From Vakil N et al. Am J Gastroenterol 2006;101:1900-20.
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Epidemiologi:
Barat 10-20%, Asia 3-5 %, Jepang: 13-15 % , IND 13 %
usia lanjut, pria, ras, riwayat keluarga, ekonomi tinggi, IMT tinggi, dan merokok.
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Patofisiologi:
- Kontak refluksat & mukosa esofagus - Penurunan resistensi esofagus - Gangguan sensitifitas persepsi sentral/perifer mukosa esofagus - Potensi perusak: as. Lambung, pepsin, garam
empedu, ensim pankreas.
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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.
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There is no single diagnostic gold
standard for GERD
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Diagnosis:
Anamnesis: GERD Q
Penunjang menyingkirkan diagnosis: laboratorium, EKG, USG, foto toraks, dan
lainnya sesuai indikasi).
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!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.
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!Empiric trial !Barium esophagram !Endoscopy !Manometry !pH testing !Impedance
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!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.
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!Screening for Barretts in selected patients !Persistent vomiting !Suspected extraesophageal
GERD
From Gastrointest Endosc 2007;66:219-24.
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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
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From Kahrilas PJ. N Engl J Med 2008;359:1700-7.
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From Nayar DS et al. Gastrointest Endosc 2004;60:253-7.
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Reflux symptoms/mucosal breaks not visible in standard video endoscopy
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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
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! 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.
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From Smout A. Aliment Pharmacol Ther 2007;26(Suppl2):7-12.
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!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
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!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
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!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
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!Indications Esophagitis Stricture Barretts metaplasia Medication failure
!Purpose of surgery ! restoration the LES
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!In development with ongoing studies
!Most try to improve LES function in some manner
!Not quite ready for prime time in community practice
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! Decrease in symptom score
! Decreased PPI ! No effect on LESP ! No effect on acid
exposure
! Some serious thermal injury complications
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!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
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TERIMA KASIH