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What is GERD?
Gastroesophageal
Reflux Disease:
symptoms of
mucosal damage
produced by
abnormal reflux of
gastric contents
into the esophagus
GERD: Background
Pulmonary ENT
Asthma Hoarseness
Aspiration pneumonia Laryngitis
Chronic bronchitis Pharyngitis
Pulmonary fibrosis Chronic cough
Globus sensation
Dysphonia
Other Sinusitis
Chest pain Subglottic stenosis
Dental erosion Laryngeal cancer
Potential Oral and Laryngopharyngeal Signs Associated
with GERD
Dysphagia
– Difficulty swallowing: food sticks or
hangs up
Odynophagia
– Retrosternal pain with swallowing
Bleeding
Alarm –Sign
– Alarm Signs/Symptoms
– Dysphagia
– GI bleeding
– Odynophagia
– Vomiting
– Weight loss
– Iron deficiency anemia
When to Perform Diagnostic Tests
Uncertain diagnosis
Atypical symptoms
Symptoms associated with complications
Inadequate response to therapy
Recurrent symptoms
Prior to anti-reflux surgery
Diagnostic Tests for GERD
Barium swallow
Endoscopy
Ambulatory pH monitoring
Esophageal manometry
Treatment Goals for GERD
Eliminate symptoms
Heal esophagitis
Manage or prevent
complications
Maintain remission
Lifestyle Modifications are
Cornerstone of GERD Therapy
Elevate head of bed 4-6 inches
Avoid eating within 2-3 hours of bedtime
Lose weight if overweight
Stop smoking
Modify diet
– Eat more frequent but smaller meals
– Avoid fatty/fried food, peppermint,
chocolate, alcohol, carbonated beverages,
coffee and tea
medications
Effectiveness of Medical Therapies for GERD
Treatment Response
Lifestyle modifications/antacids 20 %
H2-receptor antagonists 50 %
Single-dose PPI 80 %
Improve compliance
Optimize pharmacokinetics
– Adjust timing of medication to 15 – 30
minutes before meals (as opposed to
bedtime)
– Allows for high blood level to interact with
parietal cell proton pump activated by the
meal
Consider switching to a different PPI
GERD is a Chronic Relapsing
Condition
Esophagitis relapses quickly after cessation
of therapy
– > 50 % relapse within 2 months
– > 80 % relapse within 6 months
Effective maintenance therapy is imperative
Mempertahankan pH >4 adalah penting untuk
penatalaksanaan GERD
Lama mempertahankan pH >4 berbanding
lurus dengan angka kesembuhan pasien GERD
Pasien sembuh
setelah 8 minggu (%)
100
80
60
40
20
0
2 4 6 8 10 12 14 16 18 20 22
Lama pH lambung >4 ( jam)
Joelson & Johnson. GUT 1989; 30:1523-1525
Bell et al. Digestion 1992;51 Suppl1:59-67
When to Discuss Anti-Reflux Surgery
with Patients
Intractable GERD – rare
– Difficult to manage strictures
– Severe bleeding from esophagitis
– Non-healing ulcers
GERD requiring long-term PPI-BID in a healthy young
patient
Persistent regurgitation/aspiration symptoms
Not Barrett’s esophagus alone
Surgical Treatment
Decrease in symptom
score
Decreased PPI
No effect on LESP
No effect on acid
exposure
Erosive/ulcerative esophagitis
Barrett’s esophagus
Adenocarcinoma
Erosive Esophagitis
Peptic Stricture
39
KM Fock et al. Journal of Gastroenterology and Hepatology 23 (2008) 8–22
40
Kesimpulan
Komunikasi yang baik membantu dokter dan pasien
dalam mengenali gejala GERD dan membedakannya
dengan gejala dispepsia lainnya
PPI merupakan obat terpilih untuk mengatasi GERD
pH > 4 merupakan kunci penatalaksanaan GERD
rabeprazole terbukti lebih efektif dalam mengontrol
pH > 4 vs PPI oral lainnya