gastroesophageal r eflux d isease ( gerd) dr. saptino miro , sppd
DESCRIPTION
Gastroesophageal R eflux D isease ( GERD) Dr. SAPTINO MIRO , SpPD BAGIAN ILMU PENYAKIT DALAM FK-UNAND/RS.M.DJAMIL PADANG. Pendahuluan. GER ( refluks gastroesofageal ) adalah fenomena yang dapat timbul sewaktu-waktu pada populasi umum , terutama sehabis - PowerPoint PPT PresentationTRANSCRIPT
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Gastroesophageal Gastroesophageal RReflux eflux DDisease( GERD) isease( GERD)
Dr. SAPTINO MIRO, SpPD
BAGIAN ILMU PENYAKIT DALAM FK-UNAND/RS.M.DJAMILPADANG
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PendahuluanPendahuluan
• GER ( refluks gastroesofageal ) adalah GER ( refluks gastroesofageal ) adalah
fenomena yang dapat timbul sewaktu-waktu fenomena yang dapat timbul sewaktu-waktu
pada populasi umum , terutama sehabis pada populasi umum , terutama sehabis
makan dan kemudian kembali seperti normal makan dan kemudian kembali seperti normal
refluks fisiologis.refluks fisiologis.• Dikatakan patologis (GERD) bila terjadi refluks Dikatakan patologis (GERD) bila terjadi refluks
berulang dalam waktu lama sehingga menimberulang dalam waktu lama sehingga menim
bulkan keluhan/kerusakan mukosa esofagusbulkan keluhan/kerusakan mukosa esofagus
• Terdapat peningkatan prevalensi GERDTerdapat peningkatan prevalensi GERD
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EpidemiologiEpidemiologi
• Di AS , 33% mengalami GERD
• Swedia ,12% mengalami heartburn
• Singapura ( 1998) 1.6 % ,Taiwan 6%
• Indonesia ( ?),
• M.Djamil GERD 66.4%, BRG 24.5%
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Talley et al., BMJ 2001; 323: 1294–7.de Caestecker, BMJ 2001; 323: 736–9.
Nathoo, Int J Clin Pract 2001; 55: 465–9.Quigley, Eur J Gastroenterol Hepatol 2001; 13(Suppl 1): S13–18.
Heartburn: – Burning retrosternal pain radiating upward due
to exposure of the oesophagus to acid
Esophagitis :– Endoscopically demonstrated damage to
the oesophageal mucosaGastro-esophageal reflux disease (GERD):
– Pathological reflux ranges from simple to erosive to Barrett’s
Non-erosive reflux disease (NERD):– Reflux disease in which erosion does not occur
DefinitionsDefinitions
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Pathophysiology of GERDPathophysiology of GERD• The pathophysiology of reflux disease is The pathophysiology of reflux disease is
multifactorialmultifactorial• Gastroduodenal factors :Gastroduodenal factors :• - Acid and pepsin- Acid and pepsin• - Duodenal agents- Duodenal agents• - Gastric emptying- Gastric emptying• - Helicobacter pylori- Helicobacter pylori ? ?• Gastroesophageal junction factors :Gastroesophageal junction factors :• - Transient lower esophageal sphincter- Transient lower esophageal sphincter• relaxation relaxation • - Hypotensive lower esophageal sphincters- Hypotensive lower esophageal sphincters• - Hiatal hernia- Hiatal hernia• Esophageal factors :Esophageal factors :• - Esophageal clearance- Esophageal clearance• Genetic factorsGenetic factors Fass R. GERD .2004
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Impaired mucosal defence
de Caestecker, BMJ 2001; 323:736–9.Johanson, Am J Med 2000; 108(Suppl 4A): S99–103.
salivary HCO3
Hiatus hernia
Impaired LOS (smoking, fat, alcohol)
– transient LOS relaxations
– basal toneH+
PepsinBile and
pancreatic enzymes
oesophageal clearance of acid (lying flat, alcohol, coffee)
acid output (smoking, coffee)
intragastric pressure (obesity, lying flat)
bile reflux gastric emptying (fat)
Pathophysiology of GERDPathophysiology of GERD
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PATOGENESIS GERD(1):
Refluks isi lambung kedalam esofagus merupakan hal yang normal.
Patologis bila terjadi gangguan bersihan lumen esofagus terhadap isi lambung
Proses berlangsung lama dan berulang
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PATOGENESIS GERD(2):
Terjadi penurunan resistensi jaringan mukosa esophagus
Pola hidup tertentu, pola makan, merokok, berat badan
Infeksi H pylori?Penurunan tonus sfingter esofagus
bawah ?
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GERD dan motilitas :
Kelainan motorik/motilitas esofagus akan berakibat gangguan terhadap bersihan lumen dari refluksat.
Lamanya kontak refluksat dengan mukosa esofagus disertai dengan frekuensi refluks akan dapat berakibat terjadinya GERD
Tonus LES juga dapat berakibat lebih beratnya kelainan
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GERD & Infeksi H pylori:
Peranan infeksi H.pylori dalam patogenesis GERD relatif kecil dan kurang didukung oleh data yang ada.
Ada hubungan terbalik antara infeksi H.pylori dengan strain yang virulens (Cag A Positif) dengan kejadian esofagitis, Barrett’s esophagus & adenokarsinoma esofagus
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Pola hidup & GERD:
Peranan alkohol, diet serta faktor psikis tidak signifikan dalam patogenesis GERD.
Beberapa studi observasional telah menunjukkan pengaruh merokok dan berat badan lebih sebagai faktor risiko terjadinya GERD
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DIAGNOSIS GERD:• Standar baku diagnosis GERD adalah
endoskopi saluran cerna bagian atas (SCBA) dengan ditemukannya mucosal break di esophagus
• Anamnesis yang cermat merupakan alat utama untuk menegakkan diagnosis GERD
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Diagnosis NERD:
Gejala klinik tipikal GERD Tidak ditemukannya mucosal break pada
pemeriksaan endoskopi SCBA Pemeriksaan pH esofagus dengan hasil positif Terapi empiris yang banyak dikenal dengan
Proton Pump Inhibitor (PPI) Test dengan hasil positif.
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DiagnosisDiagnosisGERD Endoscopi sal. cerna bgn atas kerusakan jaringan.6
NERD
o Tidak ada kerusakan jaringan (endoskopi)
o Pemeriksaan pH esophagus hasil (+)
o Terapi empiris (PPI test) hasil (+)
Anamnesis.7 dan pemeriksan penunjang lainnya
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Pemeriksaan penunjang GERD:
EndoskopiPemeriksaan histopatologiPemeriksaan pH metri 24 jamPenunjang diagnostik lain:
Esofagografi dengan barium, Manometri esofagus
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One or more mucosal breaks, no longer than 5 mm, that do not extend between the tops of two mucosal folds
Grade AOne or more mucosal breaks, more than 5 mm long, that do not extend between the tops of two mucosal folds
Grade B
One or more mucosal breaks, that are continuous between the tops of two or more mucosal folds, but which involve less than 75% of the circumference
Grade COne or more mucosal breaks, that involve at least 75% ofthe oesophageal circumference
Grade D
Lundell et al., Gut 1999; 45: 172–80.
Los Angeles classification system for esophagitis
Los Angeles classification system for esophagitis
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Savary & Miller. The Esophagus. In: Handbook & Atlas of Endoscopy. Solothurn, Switzerland: Verlag Gassman AG, 1978: 119–205.
Savary-Miller classification of esophagitis
Savary-Miller classification of esophagitis
Grade I One or several erosions in one mucosal fold
Grade II Several erosions in several mucosal folds,
the erosions can merge
Grade III Erosions surrounding the oesophageal circumference
Grade IV Ulcer(s), strictures, shortening of the oesophagus
Grade V Barrett’s epithelium
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Quigley, Eur J Gastroenterol Hepatol 2001; 13(Suppl 1): S13–18.Nathoo, Int J Clin Pract 2001; 55: 465–9.
www.gastrolab.net
Savary-Miller classification
One or several erosions in one mucosal fold
Grade I esophagitisGrade I esophagitis
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www.gastrolab.net
Savary-Miller classification
Several erosions in several mucosal folds, the erosions can merge
Grade II esophagitisGrade II esophagitis
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Savary-Miller classification
Erosions surrounding the oesophageal circumference
Grade III esophagitisGrade III esophagitis
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Savary-Miller classification
Ulcer(s), shortening of the oesophagus
Grade IV esophagitisGrade IV esophagitis
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Savary-Miller classification
Moderate Barrett’s oesophagus
Grade V esophagitisGrade V esophagitis
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Nadel, UCHC.
Savary-Miller classification
Stricture
Grade IV esophagitisGrade IV esophagitis
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Savary-Miller classification
Moderate Barrett’s oesophagus
Grade V esophagitisGrade V esophagitis
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Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm
Savary-Miller classification
Severe Barrett’s oesophagus
Grade V esophagitisGrade V esophagitis
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Nadel/Saint Francis Hospital. In: Gastrointestinal Pathology. Fenoglio-Preiser, New York: Raven Press, 1989: 96–100.
Adenocarcinoma of the esophagus
Adenocarcinoma of the esophagus
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Odynophagia
Dysphagia
Vomiting
Bleeding
Weight loss
Alarm features
Nathoo, Int J Clin Pract 2001; 55: 465–9.
Alarm features for GERDAlarm features for GERD
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ALGORITME TATA LAKSANA GERD PADA PELAYANAN KESEHATAN LINI PERTAMA
GEJALA KHAS GERD
Gejala alarmUmur > 40 th Tanpa gejala alarm
Terapi empirikTes PPI
Respon menetap Respon baik
Terapi min-4 minggu
On demand therapy
kambuh
Endoskopi
Konsensus Gerd ,2004
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Hiatus hernia
Esophageal stricture
Esophageal cancer
Chest pain of cardiac origin
Functional dyspepsia
Nathoo, Int J Clin Pract 2001; 55: 465–9.
Differential diagnosis of GERDDifferential diagnosis of GERDDifferential diagnosis of GERDDifferential diagnosis of GERD
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PPIs H2RAs
Lifestyle modifications
Prokinetic motility agents
Antacids and alginates
Hatlebakk & Berstad, Clin Pharmacokinet 1996; 31: 386–406.
Approaches
GERD treatment optionsGERD treatment optionsGERD treatment optionsGERD treatment options
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Reduce weight
Stop smoking
Avoid reflux-promoting agents (e.g. alcohol, coffee, some foods) (not evidence based)
Elevate headof bed
Modifications
Eat small meals,no late meals,
reduce fat
Lifestyle modifications for the Lifestyle modifications for the management of GERDmanagement of GERD
Lifestyle modifications for the Lifestyle modifications for the management of GERDmanagement of GERD
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PRINSIP TERAPI
• PENGENDALIAN pH asam lambungPENGENDALIAN pH asam lambung
enzim pepsin bekerja pada pH ideal = 2-2.5enzim pepsin bekerja pada pH ideal = 2-2.5
pada pH > 4 aktivitas pepsin menurun pada pH > 4 aktivitas pepsin menurun
drastisdrastis• Enzim pepsin bekerja mencerna dinding Enzim pepsin bekerja mencerna dinding
protein lambungprotein lambung
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PENGOBATAN GERD:
Menghilangkan gejala / keluhanMenyembuhkan lesi esofagusMencegah kekambuhanMemperbaiki kualitas hidupMencegah timbulnya komplikasi
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Obat-Obat Untuk GERD
PPI paling efektif dalam menghilangkan gejala serta
menyembuhkan lesi esofagitis pada GERD.17
Antasid dan H2Blocker hanya untuk menghilangkan
gejala ringan sampai sedang.18
PPI terbukti lebih cepat menyembuhkan lesi esofagitis
serta menghilangkan gejala GERD dibandingkan H2
Blocker dan prokinetik.19
Mengingat efektivitas dan cepatnya menghilangkan
gejala, pengobatan GERD harus dimulai dengan PPI
KONSENSUS NASIONAL PENATALAKSANAAN PENYAKIT KONSENSUS NASIONAL PENATALAKSANAAN PENYAKIT REFLUKS GASTROESOFAGEAL (GASTROESOPHAGEAL REFLUKS GASTROESOFAGEAL (GASTROESOPHAGEAL
REFLUX DISEASE/GERD)REFLUX DISEASE/GERD) INDONESIA 2004INDONESIA 2004
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Terapi GERD dengan PPI:
Pengobatan awal dengan PPI dengan dosis ganda selama 8 minggu dengan dosis ganda.
Selanjutnya tergantung perbaikan klinik dan endoskopi, dalam bentuk terapi on demand atau maintenance therapy sampai 6 bulan
PPI dosis ganda selama 8 minggu dapat memberikan healing rate lebih dari 80%
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Penatalaksanaan GERDTERDUGA KASUS REFLUKS
UNINVESTIGATED INVESTIGATED
PENGOBATAN EMPIRIK 2 minggu ( PPI test ? )
TERAPI AWAL / INITIAL
Esofagitis ringan
NERD
Esofagitis sedang & berat Gejala
berulang
TERAPI PEMELIHARAAN
TERAPI “BILA PERLU”
Gejala Alarm/
Usia > 40 tahun
Keluhan berulang
PPI test : 1-2 minggu Dosis ganda (Sensitivitas 68-80%)
Indonesia GERD study group
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Gejala khas GERD•Heartburn•Regurgitasi
Gejala Alarm/Umur > 40 tahun
Tanpa gejala Alarm
Respon menetap Respon baik
Terapi minimal 4 minggu
On demand therapykekambuhan
Endoskopi
ALGORITME TATA LAKSANA GERD PADA PELAYANAN KESEHATAN LINI PERTAMA
GERD+
Indonesia GERD study group
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PPI Pengobatan awal
4-8 minggu
Algorithm Pengobatan Yang dianjurkan untuk Pasien GERD
PPIOn-Demand
PPIMaintenance
Severe EE , Serangan Yang sering
Atau Respons PPI lambat
Uninvestigated,
Mild EE
Atau NERD
Indonesia GERD study group
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PPI : Cepat dalam menghilangkan keseluruhan gejala
Cepat dalam penyembuhan
Pendekatan Step-down
Yang dipilih :
Cepat dalam penghambatan asam
Konsisten mengontrol asam pada pH>4
Sedikit interaksi dengan obat lain
Sedikit efek pada cytochrome P450
Omeprazole ? Rabeprazole ?Lanzoprazole ? Esomeprazole ? Pantoprazole ?
Pertimbangan terapi GERD
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KESIMPULANKESIMPULAN
• Terdapat peningkatan prevalensi GERDTerdapat peningkatan prevalensi GERD• Patofisiolgi multifaktor akibat peningkat Patofisiolgi multifaktor akibat peningkat an asam lambung, gangguan motilitas,dllan asam lambung, gangguan motilitas,dll• Keluhan berupa heartburn , noncardiac Keluhan berupa heartburn , noncardiac
chest-painchest-pain• Terapi life styleTerapi life style
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MINAL AIDIN WAL FAIDZINMINAL AIDIN WAL FAIDZINMAAF LAHIR DAN BATHINMAAF LAHIR DAN BATHIN
TERIMA KASIHTERIMA KASIH