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Bogi Pratomo

What is GERD?
Gastroesophageal
Reflux Disease:
symptoms of
mucosal damage
produced by
abnormal reflux of
gastric contents
into the esophagus
GERD: Background

Gastroesophageal reflux is a normal


physiologic phenomenon in most people,
particularly after a meal.

Gastroesophageal reflux disease (GERD)


occurs when the amount of gastric juice
that refluxes into the esophagus exceeds
the normal limit
Important Reasons to Diagnose and Treat
GERD

Negative impact on health-related quality of


life1
Risk factor for esophageal adenocarcinoma2

1. Revicki et al. Am J Med 1998;104:252.


2. Lagergren et al. N Engl J Med 1999;340:825.
Pathophysiology
– Lower Esophageal
Sphincter– changes in
resting pressure
(incompetent LES),
abnormal location (hiatal
hernia)
– Excess acid production
– Delayed gastric
emptying
– Decreased mucosal
resistance to acid injury
How common is heartburn?

>60 million Americans experience


heartburn/acid indigestion at least 1 time per
month (20-40% of adult population)
>15 million experience heartburn daily
Frequent heartburn (2 or more times per
week) may be associated with
gastroesophageal reflux disease (GERD)
Extraesophageal Manifestations of
GERD

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

• Edema and hyperemia of


larynx
• Vocal cord erythema,
polyps, granulomas,
ulcers
• Hyperemia and lymphoid
hyperplasia of posterior
pharynx
• Interarytenyoid changes
• Dental erosion
• Subglottic stenosis
• Laryngeal cancer
Vaezi MF, Hicks DM, Abelson TI, Richter JE. Clin Gastro Hep 2003;1:333-344.
Symptoms of Complicated 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 %

Increased-dose PPI up to 100 %


Treatment Modifications for Persistent
Symptoms

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

Most studies indicate that the majority of patients are


symptom-free (70-95%)

Recent studies suggest that after 5 years, up to 1/3 of


patients required PPI to control symptoms. At 10
years, up to 50% require PPIs

Side-effects: gas-bloat symptoms, diarrhea,


dysphagia
Endoscopic Treatments

In development with ongoing studies

Most try to improve LES function in some


manner

Not quite ready for prime time in community


practice
Stretta procedure
Stretta procedure

Decrease in symptom
score
Decreased PPI
No effect on LESP
No effect on acid
exposure

Some serious thermal


injury complications
Enteryx injection
Enteryx injection

Decreased in heartburn symptoms


Decreased 24 hour acid exposure
Decreased need for PPI

No improvement in severity of esophagitis at


EGD
Long term safety issues not known
Endoscopic suturing
Complications of GERD

Erosive/ulcerative esophagitis

Esophageal (peptic) stricture

Barrett’s esophagus

Adenocarcinoma
Erosive Esophagitis
Peptic Stricture

Barium Swallow Endoscopy


TTS Balloon Dilation of a Peptic Stricture
Barrett’s Esophagus
Esophageal Cancer

Barium Swallow Endoscopy


Algorithm GERD

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KM Fock et al. Journal of Gastroenterology and Hepatology 23 (2008) 8–22
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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