Dr. dr. Shahrul Rahman, Sp.

PD, FINASIM

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
Dr. dr. Shahrul Rahman, Sp.PD, FINASIM

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
Definisi:
GERD merupakan suatu penyakit kronis yang sering
dijumpai yang disebabkan karena aliran balik
(retrograde) dari isi lambung kembali ke esofagus.
 Heartburn merupakan gejala yang utama.
 WHAT IS GASTROESOPHAGEAL REFLUX
( GER )

- DIGESTIVE DISORDER THAT CAUSED BY GASTRIC ACID

FLOWING FROM THE STOMACH INTO THE ESOPHAGUS.

- GER  OCCURS WHEN THE LOWER ESOPHAGUS

SPINCTER (LES ) OPENS SPONTANEOUSLY FOR
VARYING PERIODES OF TIME, OR DOES NOT CLOSE
PROPERLY .

STOMACH CONTENTS RISE UP INTO THE

ESOPHAGUS.
WHEN REFLUXED STOMACH ACID TOUCHES THE LINING
OF ESOPHAGUS IT MAY CAUSE A BURNING SENSATION
IN THE CHEST OR THROAT.

HEARTBURN

PERSISTENT REFLUX THAT OCCURS MORE THAN

TWICE A WEEK  CONSIDER GERD .

SERIOUS PROBLEMS

PEOPLE OF ALL AGES CAN HAVE GERD

Patogenesa:
Normal barier terdiri dari lower esofageal sphincter dan
diafragma crural yang terletak pada gastroesofageal
junction
Patologis: relaksasi yang tidak tepat dari lower esofageal
sphincter.
: bersihan esofagus
: gastric emptying time melambat
Kelainan yang terjadi selain berhubungan dengan jumlah
dan keasaman bahan yang di-reflukskan, juga terhadap
lamanya kontak antara bahan yang di-reflukskan dengan
mukosa esofagus
PATOGENESA
REFLUX MECHANISM

Negative intra
Thoracic pressure

Positive intra Gastric

pressure

Positive intra
Abdominal pressure
ANTI REFLUX MECHANISM

Saliva
&Esoph.motility
Mucosal
Diaphrag aposition
ma Cruz LES tone

Intra
Abd.press.
Angle of His

Prompt Gastric
emptying
Causes of GERD
FACTORS THAT MAY CONTRIBUTE GERD

- OBESITY
- PREGNANCY
- SMOKING

- ANATOMICAL ABNORMALITY
 HIATAL HERNIA
COMMON FOODS THAT CAN WORSEN
REFLUX SYMPTOMS.

- SODAS THAT CONTAIN COFFEINE.

- CHOCOLATE.
- PEPPERMINT.
- SPICY FOOD.
- ACIDIC FOOD LIKE ORANGES,
TOMATOES AND PIZZA.
- FRIED AND FATTY FOODS.
UP TO HALF OF GERD PATIENTS HAVE
DYSPEPSIA

A SYNDROME CONSISTING OF THE FOLLOWING

- PAIN AND DISCOMFORT IN THE UPPER

ABDOMEN.
- FULLNESS IN THE STOMACH.
- NAUSEA AFTER EATING.
 OTHER SYMPTOMS OF GERD

- COUGHING AND RESPIRATORY SYMPTOMS.

ASTHMATIC SYMPTOMS
- COUGHING
- WHEEZING
 MEDICAL CONDITIONS ASSOCIATED WITH
GASTROESOPHAGEAL REFLUX DISEASE

ASSOCIATED CONDITION MECHANISM OF RISK

Obesity Increased intra-abdominal pressure

Diabetes - melitus Delayed gastric emptying
Zollinger-Ellison syndrome Increased acid output
Pregnancy Increased intra-abdominal pressure,
weakened LES
Myotomy in achalasia Destroyed LES
Sicca syndrome Impaired esophageal clearance
Psychiatric disease Impaired esophageal motility
Mental retardation of childhood Impaired esophageal motility

LES = LOWER ESOPHAGEAL SPHINCTER HOT TOPIC : GERD/DYSPEPSI

 Range of presentation of
GERD
Typical symptoms
(Heartburn/regurgitation) Atypical symptoms Complications

With Chest pain Oesophageal

oesophagitis (visceral erosions
hyperalgesia) and/or ulcers
Without
oesophagitis Hoarseness Stricture
(‘reflux
laryngitis’)

Asthma, Barrett’s
chronic cough, oesophagus
wheezing

Dental erosions Oesophageal

adenocarcinoma

Nathoo, Int J Clin Pract 2001; 55: 465–9.

Table Atypical Signs of GERD
Diagnosis GERD
• Barium swallow
• PPI test
• Esophagogastroscopy
- Savary-Miller
- Klasifikasi LA
• 24-hour pH monitoring
• Manometry
ADDITIONAL TEST FOR DIAGNOSIS

 BARIUM SWALLOW RADIOGRAPH.

 - HIATAL HERNIA.
- OTHER STRUCTURAL OR
ANATOMICAL PROBLEMS OF THE
ESOPHAGUS.
- ULCER CAN BE OBSERVED.
 UPPER ENDOSCOPY

 MORE ACURATE.
SEE THE SURFACE OF ESOPHAGUS.

- Ph MONITORING  AMBULATORY
24 - 48 HOURS.
 Test PPI
• Akurat dan cost-effective
- pada gejala refluks yang tipikal
- non-cardiac chest pain
• Penghematan biaya yang bermakna karena diagnostik
tidak invasif yang dilakukan.
• Hasil yang menjanjikan pada penyakit extraesophageal
• PPI dosis tinggi selama 1-2 pekan  (+) bila terdapat
perbaikan 50 – 75% dari gejala yang terjadi
 Test PPI
• Mudah dilakukan
• Tidak dibutuhkan keahlian yang canggih
• Sangat efektif karena dapat dilakukan pada setiap
penderita.
• Sensitivitas yang baik untuk gejala esofagus (>85%)
• Penyakit supraesofageal (paling tidak 70%)

 Kerugian: False positif (respon plasebo)

: False negatif (dosis tidak adekuat)
 American College of Gastroenterology Guidelines 1999
Endoscopy
• Tehnik pilihan untuk mengevaluasi mukosa untuk
esofagitis.
• Jika didapati Barret’s esophagus, lakukan biopsi dan
selidiki keberadaan metaplasia intestinal.
WHEN SHOULD ENDOSCOPY BE
CONSIDERED IN PATIENT WITH GERD .

- ALARM SYMPTOMS.
BLEEDING, ABDOMINAL MASS .
- DIAGNOSTIC PROBLEMS  ATYPICAL
SYMPTOMS.
- HEARTBURN > 5 YEARS.
- FAILURE TO INITIAL TREATMENT.
- PRE OPERATIVE ASSESSMENT.
Figure 1. Diagnosis and Treatment of GERD
 Tujuan Pengobatan GERD

 Menghilangkan gejala

 Menyembuhkan esofagitis

 Menangani atau mencegah komplikasi

 Mempertahankan remisi
THE KEY OF TREATMENT IS LONG TERM
MAINTENANCE .

 ALL TREATMENTS ARE BASE ON :

- DECREASE THE AMOUNT OF ACID

THAT REFLUXES FROM THE STOMACH
BACK INTO THE ESOPHAGUS.

- MAKE THE REFLUXED MATERIAL LESS

IRRITATING TO THE LINING OF THE
ESOPHAGUS.
LANGKAH LANGKAH
PENGOBATAN
 FASE I : PENGOBATAN NON
SPESIFIK.
 FASE II : PENGGUNAAN OBAT
SPESIFIK.
 FASE III: PENGOBATAN GERD YANG
BERULANG.
 FASE IV: OPERASI ANTI REFLUX.
 GERD Treatment Options

Lifestyle Antacids
modifications

PPIs Approaches H2RAs

Prokinetic Surgery
motility agents
FASE I: PENGOBATAN NON
SPESIFIK
 LIFESTYLE MODIFICATION
 ALTER EATING HABITS : SMALL
MEALS, DO NOT LIE DOWN AFTER
EATING, AVOID NOCTURNAL SNACKS.
 DIETARY CHANGES : AVOID FATTY
FOODS, LIMIT INTAKE OF
CHOCOLATE, ONIONS, PEPPERMINT
AND ALCOHOL, REDUCE INTAKE OF
CITRUS FRUIT, COFFEE AND TOMATO
PRODUCTS.
LIFESTYLE MODIFICATION
 WEIGHT REDUCTION.
 POSTURAL CHANGES DURING
SLEEP.
 ADJUST CONCURRENT
MEDICATIONS.
 REFRAIN FROM CIGARETTE
SMOKING.
LIFESTYLE CHANGES
 STOP SMOKING .
 AVOID FOODS THAT WORSEN SYMPTOMS.
 LOOSE WEIGHT.
 EAT SMALL, FREQUENT MEALS.
 WEAR LOOSE-FITTING CLOTHES.
 AVOID LYING DOWN FOR 2 – 3 HOURS
AFTER MEAL.
 RAISE THE HEAD OF YOUR BED 6 – 8
INCHES BY SECURING WOODS BLOCKS.
 Lifestyle Modifications

Reduce weight

Stop smoking Elevate head

of bed

Modifications

Avoid reflux-promoting Eat small meals,

agents (e.g. alcohol, no late meals,
coffee, some foods) reduce fat
(not evidence based)
FASE II :PENGGUNAAN
BAHAN SISTEMIK.
 MENGURANGI SIMPTOM GERD
DIPERLUKAN PENEKAN ASAM LEBIH
KUAT DIBANDING PADA ULKUS GASTER
ATAU DUODENUM.
 PPI LEBIH CEPAT MENGURANGI
HEARTBURN DARI PADA H2R-
ANTAGONIST.
 LANSOPRAZOL TERBUKTI EFEKTIF
MENGATASI GERD
 MEDICAMENTOUS
 ANTACIDS .
First drugs recommended.
Relieve heart burn and other GERD symptoms.
Increases pH of refluxate
Quick relief of mild symptoms
Less effective than PPIs or H2RA
Adverse effects-diarrhoea, constipation,
accumulation in renal failure
 H2 BLOCKERS.
Decrease acid production.
 PPI ( PROTON PUMP INHIBITORS ).
More effective than h2 blockers.
Relieve symptoms.
Heal the esophageal lining.
 PROMOTILITY AGENTS.
 PROKINETICS .

- EFFECTIVE IN THE TREATMENT OF MILD TO

MODERATE SYMPTOMATIC GERD.

- INCREASE LES PRESSURE  PREVENT ACID

REFLUX & IMPROVES THE MOVEMENT OF
THE STOMACH.

- IMPROVES MUSCLE ACTION IN THE DIGESTIVE

TRACT.
 Who is eligible for on
demand PPI?
Suitable candidates
 Symptomatic, nonerosive GERD: up to 70% of GERD
 Mild to moderate erosive oesophagitis:70-85% of
erosive oesophagitis patients

Patients who should not use on demand

PPI Rx
 Severe erosive oesophagitis
 GERD complications (strictures, Barrett’s)
 Extraoesophageal manifestations of GERD
Table 4. Medications for Acute Treatment and
Maintenance Regimens
FASE III: PENGOBATAN
GERD BERULANG
 BILA SIMTOM TAK BERKURANG
ATAU ESOFAGITIS TAK SEMBUH
 KOMBINASI ARH-2 DENGAN
PROKINETIK.
 MENINGKATKAN DOSIS PPI LEBIH
POTEN
FASE IV: OPERASI
ANTIREFLUKS.
 DAPAT DIPERTIMBANGKAN PADA
GERD YANG BERULANG
Algorithm for the management of GERD in primary care

Typical GERD symptoms

Alarm features present Alarm features absent

PPI test

Symptom persist Symptom respond

Refer for OGD Maintain therapy four weeks

Frequent relapses, alarm features On-demand therapy

INDICATIONS OF SURGICAL
TREATMENT

1. FAILURE OF MEDICAL THERAPY.

- PERSISTENT SYMPTOMS AND ESOPHAGITIS.

- YOUNG PEOPLE WITH SEVERE DISEASE NEEDING
LONG TERM OF MEDICATION.
- INTOLERANCE TO MEDICINE.
- WISH OF PATIENT TO AVOID LIFELONG
MEDICATION.
2.COMPLICATION OF GERD .
( SURGICAL )

- ULCER.
- HEMORRHAGE.
- STRICTURE.
- BARRETT’S ESOPHAGUS.
- ATYPICAL SYMPTOMS LIKE:
 RECURRENT ASPIRATION PNEUMONIA .
 ASTHMA
BEFORE SURGERY IS VERY
IMPORTANT TO HAVE THE EXACT
DIAGNOSIS OF GERD.

 BARIUM ESOPHAGOGRAM .

 ENDOSCOPY.

 MANOMETRY.

 24 HOUR Ph METRY.
WHEN GERD IS NOT TREATED 
SERIOUS COMPLICATION :

 SEVERE CHEST PAIN  HEART

ATTACK.

 ESOPHAGEAL STRICTURE 
SWALLOWING DIFFICULT.

 BARRETT’S ESOPHAGUS.

 BLEEDING.
SYMPTOMS SUGGESTING THAT
SERIOUS DAMAGE ALREADY
OCCURRED :

 DYSPHAGIA.

 BLEEDING.

 SHORTNESS OF BREATH,
COUGHING, HOARSENESS OF VOICE.

 WEIGH LOSS.
 COMPLICATION OF REFLUX ESOPHAGITIS

 - STRICTURE 4 - 20 %

- BARRETTS ESOPHAGUS 10 - 15 %

- PEPTIC ULCERATION 2-7 %

- RISK OF MALIGNANCY 30 - 40 %
ACHALASIA
INTRODUCTION

Achalasia: a motor disorder of the esophageal smooth

muscle in which the LES does not relax properly with
swallowing, and the esophageal body under goes
nonperistaltic contraction.

Synonim:
Cardiospasm
Aperistaltic
Mega esophagus
Etiology
 Primary: ineffective control of aeurbach plexus in distal
esophagus
general disturbance of esophageal motility
viral infection
genetic
 definite ?

 Secondary: infection ( chagas’ disease )

intra luminer tumor ( cardia tumor )
extra luminar displacing (pseudocyst of
pancreas)
The incident was unfrequent

 RSCM 1984 -1988  48 cases detected

 Generally in middle age
 Male = female
Mortality rate 0-250 ( 26 countries )
 Diagnosis: clinical, radiologic investigation, manometric data

DD : - primary esophageal disorder

- pseudoachalasia

Complication : pneumonia aspiration, acute perforation,

ca. esophagus, ca. gaster & deep ulcer bleeding

Management : conservative, dilation and surgical treatment

Regurgitation and pulmonary aspiration occur
because of retention of large volumes of saliva and
ingested food in the esophagus. Patients may
complain of difficulty belching. The presence of
gastroesophageal reflux argues against achalasia; in
patients with long-standing heartburn, cessation of
heartburn and appearance of dysphagia suggest
development of achalasia on top of reflux esophagitis.
The course is usually chronic, with progressive
dysphagia and weight loss over months to
years. Achalasia associated with carcinoma is
characterized by severe weight loss and a rapid
downhill course if untreated
Pathologically
Early in disease :  dilatation of proximal esophagus
 narrowing caudal of esophagus
More chronic disease : dilation + hypertrophy + tortussity

The feature of fluoroscopy : (1) fusiform dilatation

(2) flask shaped type
(3) sigmoid shaped
Oral pharmacologic therapies are the least effective treatment
options in achalasia
Calcium channel blockers and long-acting nitrates are the two
most common medications used to treat achalasia. They
transiently reduce LES pressure by smooth muscle relaxation,
facilitating esophageal emptying.
The phosphodiesterase-5-inhibitor, sildenafil, has also been
shown to lower the LES tone and residual pressure in patients
with achalasia
Other less commonly used medications include anticholinergics
(atropine, dicyclomine, cimetropium bromide), β -adrenergic
agonists (terbutaline), and theophylline. Overall, calcium
channel blockers decrease LES pressure by 13 – 49 % and
improve patient symptoms by 0 – 75 % .
Figure Recommended treatment algorithm for patients with achalasia

PD, pneumatic dilation

I DO NOT WANT TWO
DISEASES,
ONE NATURE MADE,
ONE DOCTOR MADE!

Napoleon Boneparte, 1820

Remember, your
license…

James only has a license to

kill,

But doctors have a license

to save and also to kill