Gerd Ozidrtd Final

7/28/2019 Gerd Ozidrtd Final

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GASTROESOPHAGEALGASTROESOPHAGEALREFLUX DISEASEREFLUX DISEASE

(GERD)(GERD)

FAUZI YUSUF,SpPD KGEHFAUZI YUSUF,SpPD KGEHFINASIMFINASIM

SUBBAGIAN GASTROENTEROHEPATOLOGISUBBAGIAN GASTROENTEROHEPATOLOGIFK UNSYIAH/RSUZAFK UNSYIAH/RSUZA


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DEFINISI GERDDEFINISI GERD

Kelainan esofagus akibat refluksKelainan esofagus akibat refluks

cairan lambung dengan berbagaicairan lambung dengan berbagai

kandungannyakandungannya

Gejala klinik khas berupaGejala klinik khas berupa heartburnheartburn

(rasa terbakar di dada yang kadang-(rasa terbakar di dada yang kadang-

kadang disertai rasa nyeri dankadang disertai rasa nyeri dan

pedih),pedih), regurgitasiregurgitasi (rasa asam dan(rasa asam danpahit di lidah), nyeri epigastrium,pahit di lidah), nyeri epigastrium,

disfagia atau odinofagiadisfagia atau odinofagia


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Typical symptoms(Heartburn/regurgitation)

Atypical symptoms Complications

Withoesophagitis

Withoutoesophagitis

Chest pain(visceralhyperalgesia)

Asthma,chronic cough,

wheezing

Hoarseness

(refluxlaryngitis)

Oesophagealerosionsand/or ulcers

Stricture

Barrettsoesophagus

Oesophagealadenocarcinoma

Dental erosions

Nathoo, Int J Clin Pract2001; 55: 4659.

Range of presentationsRange of presentations

of GERDof GERD


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PATOGENESIS GERD (1)PATOGENESIS GERD (1)

Refluks isi lambung kedalamRefluks isi lambung kedalam

esofagus merupakan hal yangesofagus merupakan hal yang

normal.normal.

Patologis bila terjadi gangguanPatologis bila terjadi gangguan

bersihan lumen esofagus terhadap isibersihan lumen esofagus terhadap isi

lambunglambung

Proses berlangsung lama danProses berlangsung lama dan

berulangberulang


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PATOGENESIS GERD (2)PATOGENESIS GERD (2)

Terjadi penurunan resistensi jaringanTerjadi penurunan resistensi jaringan

mukosa esophagusmukosa esophagus

Pola hidup tertentu, pola makan,Pola hidup tertentu, pola makan,

merokok, berat badanmerokok, berat badan

Infeksi H pyloriInfeksi H pylori

Penurunan tonus sfingter esofagusPenurunan tonus sfingter esofagusbawahbawah


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DIAGNOSIS GERDDIAGNOSIS GERD

Standar baku diagnosis GERDStandar baku diagnosis GERD

adalah endoskopi saluran cernaadalah endoskopi saluran cerna

bagian atas (SCBA) denganbagian atas (SCBA) dengan

ditemukannya mucosal break diditemukannya mucosal break diesophagusesophagus

Anamnesis yang cermat merupakanAnamnesis yang cermat merupakan

alat utama untuk menegakkanalat utama untuk menegakkandiagnosis GERDdiagnosis GERD


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DIAGNOSIS NERDDIAGNOSIS NERD

Gejala klinik mirip tipikal GERDGejala klinik mirip tipikal GERDTidak ditemukannya mucosal breakTidak ditemukannya mucosal break

pada pemeriksaan endoskopi SCBApada pemeriksaan endoskopi SCBA

Pemeriksaan pH esofagus dengan hasilPemeriksaan pH esofagus dengan hasil

positifpositif

Terapi empiris yang banyak dikenalTerapi empiris yang banyak dikenal

dengan Proton Pump Inhibitor (PPI) Testdengan Proton Pump Inhibitor (PPI) Testdengan hasil positif.dengan hasil positif.


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One or more mucosal

breaks, no longer than

5 mm, that do not

extend between the

tops of two mucosalfolds

Grade A

One 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 arecontinuous between the

tops of two or more

mucosal folds, but which

involve less than 75% of

the circumference

Grade C

One or more mucosal

breaks, that involve atleast 75% of

the oesophageal

circumference

Grade D

Lundell et al., Gut1999; 45: 17280.

Los Angeles ClassificationLos Angeles Classification

System for OesophagitisSystem for Oesophagitis


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Savary & Miller. The Esophagus. In: Handbook & Atlas of Endoscopy.Solothurn, Switzerland: Verlag Gassman AG, 1978: 119205.

Savary-millerSavary-miller ClassificationClassification

Of OesophagitisOf Oesophagitis Grade IGrade I

One or several erosions in one mucosal foldOne or several erosions in one mucosal fold Grade IIGrade II

Several erosions in several mucosal folds, theSeveral erosions in several mucosal folds, theerosions can mergeerosions can merge

Grade IIIGrade III Erosions surrounding the oesophagealErosions surrounding the oesophageal

circumferencecircumference

Grade IVGrade IV Ulcer(s), strictures, shortening of theUlcer(s), strictures, shortening of the

oesophagusoesophagus Grade VGrade V

Barretts epitheliumBarretts epithelium


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Grade I oesophagitisGrade I oesophagitis

Savary-MillerSavary-Millerclassificationclassification

One or severalOne or severalerosions in oneerosions in onemucosal foldmucosal fold

Quigley, Eur J Gastroenterol Hepatol2001; 13(Suppl 1): S1318.

Nathoo, Int J Clin Pract2001; 55: 4659.www.gastrolab.net


13/24www.gastrolab.net

Grade II oesophagitisGrade II oesophagitis


Several erosions inSeveral erosions inseveral mucosalseveral mucosalfolds, the erosionsfolds, the erosionscan mergecan merge


14/24Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm

Grade III oesophagitisGrade III oesophagitis

Savary-MillerSavary-Miller

classificationclassification

ErosionsErosionssurrounding thesurrounding the

oesophagealoesophageal

circumferencecircumference


15/24Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm

Grade IV oesophagitisGrade IV oesophagitis

Savary-MillerSavary-Miller

classificationclassification

Ulcer(s), shorteningUlcer(s), shorteningof the oesophagusof the oesophagus


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Grade IV oesophagitisGrade IV oesophagitis


StrictureStricture


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Grade V oesophagitisGrade V oesophagitis


Moderate BarrettsModerate Barrettsoesophagusoesophagus

Freytag et al., Atlas of gastrointestinal endoscopy. www.home.t-online.de/home/afreytag/indexe.htm


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Moderate BarrettsModerate Barrettsoesophagusoesophagus



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Severe BarrettsSevere Barrettsoesophagusoesophagus



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PENGOBATAN GERDPENGOBATAN GERD

Menghilangkan gejala / keluhanMenghilangkan gejala / keluhan

Menyembuhkan lesi esofagusMenyembuhkan lesi esofagus

Mencegah kekambuhanMencegah kekambuhan Memperbaiki kualitas hidupMemperbaiki kualitas hidup

Mencegah timbulnya komplikasiMencegah timbulnya komplikasi


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Algorithm of the management of GERDNational Consensus in the Management of GERD in Indonesia,

Perkumpulan Gastroenterologi Indonesia/PGI 2004

Typical GERD Symptoms *Heartburn*Regurgitation

UninvestigatedInvestigated

Milde

sophag

itis

NERD

Empirical Treatment

/ PPI Test

Initial

Treatment

MaintenanceTherapyOn demand therapy

PPI test (1-2weeks)

Sensitivity: 68-80%

Sympto

msrec

urrent

orpersist

Moderate &Severe

Esophagitis

RecurrentSymptom

Alarm SymptomsAge > 40 years

Al ith P b tAlgorithm Pengobatan


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PPI

Pengobatan awal

4-8 minggu

PPI

On-Demand

PPI

Maintenance

Severe EE , Serangan

Yang sering

Atau Respons PPI

lambat

Uninvestigated,

Mild EE

Atau NERD

Indonesia GERD study group

Algorithm PengobatanAlgorithm Pengobatan

Yang dianjurkan untukYang dianjurkan untuk

Pasien GERDPasien GERD


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PPI : Cepat dalam menghilangkan keseluruhan gejala

Cepat dalam penyembuhan

Pendekatan Step-down

Pilih :

Cepat dalam penghambatan asam

Konsisten mengontrol asam pada pH>4

Sedikit interaksi dengan obat lainSedikit efek pada cytochrome P450

Omeprazole ? Rabeprazole ?

Lanzoprazole ? Esomeprazole ?

Pantoprazole ?

Pertimbangan Terapi GERD


24/24Thank You

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Gerd Ozidrtd Final