GERD

(gastroesofageal reflux
disease)
dr. DANI ROSDIANA, SpPD
Bagian Ilmu Penyakit Dalam
FK Universitas Riau

Gangguan Gastrointestinal paling banyak.
Population-based studies show that up to
15% of individuals have heartburn and/or
regurgitation at least once a week, and
7% have symptoms daily.
Gejala muncul akibat dari aliran balik
(regurgitasi)/reflux asam lambung dan
cairan lambung lainnya ke esofagus
karena barrier di gastroesophageal
junction yang tidak kompeten.
PATOFISIOLOGI
Mekanisme anti reflux normal : LES
(Lower Esophageal Sphincter), the crural
diaphragm, and the anatomical location of
the gastroesophageal junction below the
diaphragmatic hiatus.
Reflux : terjadi karena gradient tekanan
antara LES dan lambung hilang.
PATOFISIOLOGI
Refluks gastroesofageal pada pasien GERD
melalui 3 mekanisme:
Refluks spontan pada saat relaksasi LES yang
tidak adekuat
Aliran retrograd mendahului kembalinya tonus
LES setelah menelan
Tekanan intra abdomen meningkat
Pertahanan esofageal
1. Pemisah anti refluks TONUS LES menurun
2. Bersihan asam : semakin lama kontak
dengan asam esofagitis
3. Epithelial resistance : membran sel,
intraceluller junction, aliran darah esofagus
Kekuatan refluksat
1. Sekresi gastrik
2. Daya pilorik

Neraca
Shay & Sun
FAKTOR
AGRESIF
FAKTOR
DEFENSIF
PATOGENESIS GERD
GERD
penyembuhan
PATOFISIOLOGI
Penyebab MENURUNNYA LES:
Kelemahan otot (muscle weakness) sering penyebab tidak jelas
LES incompetence ; scleroderma-like diseases, myopathy associated
with chronic intestinal pseudo-obstruction, pregnancy, smoking,
anticholinergic drugs, smooth-muscle relaxants ( -adrenergic agents,
aminophylline, nitrates, calcium channel blockers, and
phosphodiesterase inhibitors)
Surgical damage to the LES
Apart from incompetent barriers, gastric contents are most likely to reflux
(1) when gastric volume is increased (after meals, in pyloric
obstruction, in gastric stasis, during acid hypersecretion states)
(2) when gastric contents are near the gastroesophageal junction (in
recumbency, bending down, hiatal hernia)
(3) when gastric pressure is increased (obesity, pregnancy, ascites, tight
clothes).
Obesity is a risk factor for GERD.
MANIFESTASI KLINIK
Heartburn and regurgitation of sour material into the
mouth are the characteristic symptoms of GERD.
Angina-like or atypical chest pain.
Persistent dysphagia suggests development of a peptic
stricture.
Extraesophageal manifestations of GERD are due to reflux
of gastric contents into the pharynx, larynx,
tracheobronchial tree, nose, and mouth.
chronic cough, laryngitis, and pharyngitis, Morning
hoarseness, chronic bronchitis, asthma, pulmonary
fibrosis, chronic obstructive pulmonary disease, or
pneumonia. Chronic sinusitis and dental decay have also
been ascribed to GERD.
DIAGNOSIS ?
Anamnesis : bisa ditegakkan hanya dengan ng
baik.
Diagnostic studies are indicated in patients with
persistent symptoms or symptoms while on
therapy, or in those with complications.
The diagnostic approach to GERD can be divided
into three categories: (1) documentation of
mucosal injury, (2) documentation and
quantitation of reflux, and (3) definition of the
pathophysiology.
DIAGNOSIS ?
Endoskopi upper GI tract (Gastroskopi).
Standar baku diagnosis GERD mucosal break di
esofagus
Derajat
Kerusakan
Gambaran Endoskopik
A Erosi kecil kecil pada mukosa esofagus dengan diameter < 5 mm
B Erosi mukosa/mucosal fold diameter > 5 mm tanpa berhubungan
C Lesi yang konfluen tapi tidak mengenai /mengelilingi seluruh lumen
D Lesi mukosa esofagus yang bersifat sirkumferensial (mengelilingi
seluruh lumen esofagus)
KLASIFIKASI LOS ANGELES
DIAGNOSIS ?
BARIUM ESOFAGOGRAFI.
Kurang peka/kurang sensitive dibandingkan dengan
Gastroskopi
Bermanfaat pada kasus-kasus:
1. Stenosis esofagus
2. Hiatus hernia
PPI test /supresi asam.
Terapi empirik untuk menilai gejala GERD
PPI dosis tinggi selama 1 2minggu : perbaikan klinis
50 -70 %
Lanj.
ALARM SYMPTOM endoskopi
1. Anemia
2. hematemesis melena
3. disfagia
4. odinofagia
5. Berat badan menurun drastis
6. Riwayat keluarga kanker esofagus/lambung
7. umur > 40 tahun
PENATALAKSANAAN
The goals of treatment
Mengurangi keluhan
Menyembuhkan luka/erosi esofagitis
Mencegah komplikasi

PENATALAKSANAAN
Management mild cases :
weight reduction
sleeping with the head of the bed elevated by about 46 in. with
blocks
elimination of factors that increase abdominal pressure.
Not smoke and avoid consuming fatty foods, coffee, chocolate,
alcohol, mint, orange juice, and certain medications (such as
anticholinergic drugs, calcium channel blockers, and other
smooth-muscle relaxants).
Avoid ingesting large quantities of fluids with meals.
H2 receptor blocking agents (cimetidine, 300 mg qid; ranitidine,
150 mg bid; famotidine, 20 mg bid; nizatidine, 150 mg bid) are
effective in symptom relief.
PPIs are more effective and more commonly used.
The PPIs are comparably effective: omeprazole
(20 mg/d), lansoprazole (30 mg/d),
pantoprazole (40 mg/d), esomeprazole (40
mg/d), or rabeprazole (20 mg/d) for 8 weeks
can heal erosive esophagitis in up to 90% of
patients.
The PPI should be taken 30 min before
breakfast.
Refractory patients can double the dose.
Since GERD is a chronic disease, long-term
maintenance therapy is often required, and
symptoms may relapse in up to 80% of patients
within 1 year if therapy is discontinued.
PPIs are most effective in preventing recurrences. The side
effects of PPI therapy are generally minimal.
Vitamin B12 and calcium absorption may be compromised
by the treatment.
Antireflux surgery, in which the gastric fundus is wrapped
around the esophagus (fundoplication), creates an antireflux
barrier.
Sucralfate is particularly useful in these cases, as it also
serves as a mucosal protector.
PROTON PUMP INHIBITOR
Drug of choice GERD
Bekerja langsung pada pompa proton sel
parietal mempengaruhi enzim H, K ATP-ase
dalam tahap akhir pembentukan asam lambung
Dose:
Omeprazole : 2 x 20 mg
Lanzoprazole : 2 x 30 mg
Pantoprazole : 2 x 40 mg
Rabeprazole : 2 x 10 mg
Esomeprazole : 2 x 40 mg
PROTON PUMP INHIBITOR
Lama terapi:
INISIAL : 6 8 MINGGU
MAINTENANCE : 4 BULAN on demand
Efektivitas meningkat dengan
penambahan golongan prokinetik

GOLONGAN PROKINETIK
METOKLOPRAMID
Antagonis reseptor dopamin
Efektivitas rendah dalam mengurangi gejala
Hati-hati : gejala extra pramidal
Dosis : 3 x 10 mg
GOLONGAN PROKINETIK
DOMPERIDON
Antagonis reseptor dopamin
EFEK samping minimal karena tidak melewati
sawar otak
Meningkatkan tonus LES
Mempercepat pengosongan lambung
Dosis : 3 x 10 mg
GOLONGAN PROKINETIK
CISAPRIDE
Mempercepat pengosongan lambung
Meningkatkan tonus LES
Efektivitas lebih baik dibandingkan
domperidon
Dosis : 3 x 10 mg
KOMPLIKASI
Striktur Esofagus
penyempitan esofagus. Diameter < 13
mm dilatasi busi
Perdarahan
Esofagus Barrett