Download - Gerd
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GERD
PenatalaksanaanPenyakit
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Penyakit Refluks Gastroesofageal(Gastroesophageal Reflux Disease)Adalah penyakit saluran cerna bagian atasyang terbilang baru.
Terkadang sulit menegakkan diagnosis,karenakeluhan menyerupai keluhan penyakit jantung,dan paru seperti heartburn dan nyeri dada.
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Definisi GERDKelainan dimana refluks cairan lambung yang berulang kedalam esofagus akan menimbulkan Heart burn ,disfagi,nyeri epigastrium.GERD : Esofagitis erosif, simptom + kerusakan mukosa ( Mucosal break)
NERD : Gejala tipikal refluks tanpa kerusakan mukosa esofagus
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Standar baku untuk diagnosis GERD adalahEndoskopi saluran cerna bagian atas denganDitemukannya mucosal break di esofagus.
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GERD FKUI/RSCM , Jakarta
• Pada pasien dispepsia :
•Endoskopi , Esofagitis 22,8 %
• 90 % esofagitis ringan
Lelosutan 1998
• Peningkatan prevalensi pada pasien
dispepsia ( n= 1718 )
• 1997 : 5,7%
• 2002 : 25,18 %
Rata rata 13,13 %
Syam AF, 2003
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Mengapa GERD meningkat di Asia ?• Faktor etnik;
Multi ras Malaysia : GERD India / cina : risiko 3,25
Melayu/cina risiko 1,67
• BMI :
> 25 OR 1,41
•Hiatus Hernia OR 4,21
• Alkohol : OR 2,42
•Makanan berminyak OR 6,56
•Over eating OR 1,99
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Sebab GERD
• Abnormalnya spingter esofageal
• Hiatal hernia pada esofagus
• Lambatnya pengosongan lambung
• Motilitas yang terganggu
• Lambatnya pembersihan reflux oleh ludah
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HIASTUS HERNIA
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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
Erosi pd satu lipatan mukosa
Grade I esofagitisGrade I esofagitis
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www.gastrolab.net
Savary-Miller classification
Erosi pd beberapa lipatan mukosa
Grade II esofagitisGrade II esofagitis
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Spectrum Of Endoscopic Findings with GERD
Normal esophagus Grade 3 esophagitis
Grade 4 esophagitis Barrett’s esophagus
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Nadel/Saint Francis Hospital. In: Gastrointestinal Pathology. Fenoglio-Preiser, New York: Raven Press, 1989: 96–100.
Adenocarcinoma esofagus Adenocarcinoma esofagus
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Akibatnya
• Merusak esofagus
• Inflamasi /esofagitis
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Gejala
• Heartburn
• Regurgitasi
• Nausea
• Disfagia
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Komplikasi
• Ulkus• Striktur esofagus• Barret’s esofagus• Batuk, asma• Bengkak pada tenggorokan dan larynx• Gangguan pada paru• Berkumpulnya cairan di sinus dan
tengah hidung
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Diagnosa
• Pengobatan percobaan (omeprazole)
• Radiologi
• Endoskopi
• Test keasaman esofagus
• Test pengosongan lambung
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PENGOBATAN ATAS ALUR PROSES DIAGNOSTIK
TERDUGA KASUS GERD
Tidak terinvestigasi Terinvestigasi
Terapi Empirik/Tes PPI Terapi inisial
Terapi PemeliharaanTerapi Bila perlu
PPI test 1-2 minggu dosis ganda
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PILIHAN TERAPI EMPIRIS UNTUK PENYAKIT REFLUX
Kemungkinan GERD
Terapi Empiris
Investigasi(endoskopi)
Eradikasi H,Pylori.
PPIH2RA dan CisaprideH2RA atau CisaprideAntasidaGaya hidup
“Step Down” “ Step Up”
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Makanan yang meningkatkan gejala:
• Kafein• Pepermint• Berlemak• Coklat• Pedas• Buah yang asam (sitrun, juice)• Alkohol• Tomat
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1. Peranan infeksi Helicobacter pylori
– Pengaruh dari infeksi H. pylori terhadap GERD merupakan konsekuensi logis dari gastritis serta pengaruhnya terhadap sekresi asam lambung.
Beberapa issue kontroversial menyangkut patogenesis GERD diantaranya :
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HELICOBACTER PYLORI
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2. Peranan Kebiasaan / Gaya Hidup
– Peranan alkohol, merokok, diet serta faktor
psikis
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3. Peranan Motilitas Esofagus
– Kelainan motorik/motilitas esofagus mempunyai peranan
dalam patogenesis GERD. Menurunnya bersihan esofagus,
disfungsi spingter esofagus, pengosongan lambung yang
lambat serta hipersensitivitas viseral sangat mungkin
memegang peranan pada patogenesis GERD.
4. Hipersensitivitas Viseral
– Akhir-akhir ini telah diketahui tentang peranan non-acidic
reflux/gas refluks dalam patogenesis GERD, yang
didasarkan atas hipersensitivitas viseral.
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PENATALAKSANAAN GERD
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Tujuan Tujuan Penatalaksanaan Penatalaksanaan
GERDGERDMenghilangkan simptom GERD Menyembuhkan kelainan mukosa;
erosi, Ulserasi. Mencegah Komplikasi Meningkatkan kualitas hidup
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Penatalaksanaan GERD• Memperbaiki Life style
• diet : rokok, coklat, kopi
• waktu makan sebelum tidur
•posisi tidur dengan kepala lebih tinggi
• Terapi Obat
• Supresi asam : Proton pump inhibitor(PPI)
H2 receptor Antagonist
Antasida
• Prokinetik : Cisapride
•Sitoprotektif : Sukralfat
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Apakah ada perbedaan efektifitas berbagai jenis PPI?
Secara keseluruhan PPI dosis standar :
Omeprazol 20 mg,
Lansoprazol 30 mg,
Rabeprazol 20 mg
Pantoprazol 40 mg dan
Es-Omeprazol 40 mg
menyembuhkan 85-90 % Esofagitis refluks Wolfe MM,Sachs G 2000
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Andy-Lou and Kun-Lou