GERD (gastroesophageal refluks disease)

7/30/2019 GERD (gastroesophageal refluks disease)

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Dr. Abdul Rohman SpP

RELATED TO

ACUTE ASTHMA ATTACK

GERD


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TRIGGER COMORBID

The Relationship Between GERD and Asthma

ASTHMA

COMORBI

D

Been

Discussed

Occur

TogetherUnclear

The prevalence of GERD in asthmatics : 34 89 %

1892, Sir W Osler severe paroxysm of asthma may beinduced by overloading the stomach, or by taking certain

article of food.The Expert Panel Report 3 : Guidelines for the Diagnosis and Management

of Asthma GERD as a comorbid condition of asthma and recommendsmedical management of GERD in appropriate patients


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GERDCAUSE

TRIGGER

EXACERBATE

MANY PULM DISEASE

CHRONIC COUGH & ASTHMA

IPF, CYSTIC FIBROSIS, COPD & CHRONIC BRONCHITIS


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GERDASTHMA

Esophageal Sphincter Pressure

CoughIntraabdominal pressure

INDIRECT Reflex TheoryForegut Smooth Muscle

Same Innervation

DIRECTInflammation caused by

Aspiration after reflux

Reflux Theory


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PATHOPHYSIOLOGY OF THE PULMONARY MANIFESTATION OF GERD

GERD ASTHMA

MANY POTENTIAL FACTORS THAT PROMOTE GERD IN ASTHMATICS

Microaspiration

Vagally mediated reflux

Heightened bronchial

reactivity

Local axonal reflex

Autonomic dysregulation (hypervagal state)

An increased pressure between the thorax and abdominal cavity

Asthma medication

Hiatus hernia

Hyperinflation associated with bronchospasm that alters crural diaphragma function

Neurogenic inflamation


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Vagal Mediated Reflex

Hiperaktivitas Bronkus

Micro Aspiration

Neurogenic Inflammation

Local Axonal Reflex

GERD

Psikis

Lingkungan

Keturunan

Obesity Fatty mealPregnancy Heavy meal

Tight Fitting garment Spicy food

Rapid eating behaviour Coffee, tea, onions

Reclining after eating Cigarette smoking

Emotional stress Medication

Larynx

Middle ear

Nasal

Oral

Pharynx/Larynx

Airway- Chronic cough

- Aspiration Pneumonia

ASMA

- P Thorax Abdomen- Hiperinflation

Diafragma Mendatar

- Medication

- Hiatus Hernia

- Hipervagal State

Asam Lambung

LES

InspirasiInfeksi

Alergen

Fisik


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Gejala Klinis GERD pada Asma

Heartburn Regurgitasi Dysfagi Nyeri dada Waterbrash

Agus DS dkk 80,6 % 100 % 19,4 % 80,6 % 38,9 %

Taley dkk 40 75 8 51 -

Field dkk 77 55 24 - -

Roussos dkk 81 57 - - -

OConnels 72 50 - - -

Nakase dkk 68,9 - 4,7 - 34,9

Esophageal 4 Gejala Utama : - Heartburn- Regurgitasi

- Dysfagi

- waterbrash

CATATAN : - Asia (heartburn) - sedikit susah pahami arti heartburn- Agus DS dkk : heartburn 89,6 %

terlalu mengarahkan

?


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Suspected extra-esophageal manifestation of GERD

Middle ear/eustachian tube : - Glue ear - Otitis media - Otalgia

Nasal/Sinusal : - Chronic sinusitis - Postnasal drip

Oral : - Dental erosions - Aphthous ulcers

Pharynx/Larynx : - Pharyngitis - Chronic laryngitis- Laryngospasm - Cancer

- Globus

Airways

- Chronic cough

- Aspiration pneumonia

-

- Tracheobronhitis

- IPF

- Cystic fibrosis- COPD

- Chronic bronchitis

- Sleep apnea

- Bronchiectasis

- Noncardiac chest pain

Asthma


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GEJALA PERNAPASAN (BATUK, SESAK, MENGI, NAPAS

BERAT)

TIMBUL SELAMA DAN SETELAH EPISODE REFLUKSGASTROESOFAGEAL

Harding dkk Asma + GERD (pH esofagus 24 jam)RARS: 78 %

Agus DS dkk Asma + GERD RARS = 52,8 %

- Penggunaan bronkodilator saat episode refluks : 50 %

Field dkk - Asma + GERD RARS = 41 %

- Bronkodilator inhalasi saat episode refluks : 28 %

Roussos dkk Asma RARS = 65,2 %

- Bronkodilator setelah episode refluks : 52,1 %

Erkstrom dkk Asma sedang & berat + GERD RARS = 56,25 %

Talib dkk Asma + GERD RARS = 70 %

REFLUX ASSOCIATED RESPIRATORY SYMPTOMS

(RARS)


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HUBUNGAN OBAT ASMA - ESOFAGITIS

Kepustakaan : bronkodilator oral (teofilin,

agonis ) dapat me tekanan LES - me kejadian refluks asam- me total waktu refluks

` Agus DS dkk : steroid oral 15,6 %, steroid inhalasi 46,9 %,

bronkodilator oral 84,4 % dan bronkodilator inhalasi 59,4 % 59,3 % esofagitis erosif e.c. pemakai bronkodilator oral

- Tidak bermakna untuk pengguna obat asma dan bukan

- Bronkodilator po resiko lebih tinggi (esofagitis erosif)

Resiko lesi


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Baku emas : Endoskopi mucosal break esofagus

Klinis + sistim skoring gejala + penunjang

pH esofagus + terapi empiris

Tipikal GERD (heartburn dan regurgitasi) mulai terapi( sensitivitas 93 % dan spesivisitas 71 % )

GERD

DIAGNOSIS


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ASMA- Gejala episodik : sesak napas, batuk, mengi, rasa berat di dada

- Timbul /memburuk terutama malam/dini hari

- Diawali faktor pencetus yang bersifat individu- Respons thd pemberian bronkodilator

- Riwayat keluarga (atopi), alergi

+

PEMERIKSAAN JASMANI

+

spirometri

DIAGNOSIS


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Diagnosing GERD in Patients with Asthma

All asthmatics asked about GERD (Eso- and Extraesophageal)- whether frequent cough and hoarseness are presented

- whether asthma symptoms occur after meals or when lyingdown

In addition, inhaler use when experiencing GERD symptomsshould be assessed

If typical GERD symptoms are present, a trial ofpharmacologic therapy is warranted.

Empiric therapy is considered successful if asthma outcomes

are improved.

Futher testing empiric therapy is unsuccessful orhave symptoms suggesting complicated GERD

Endoscopy - pH esophagus 24 jam


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GERD should be considered in patients with :

Worsening asthma symptoms after meals or with reclining

Intractable nocturnal asthma

Whose disease is poorly controlled on antiasthma

medications

Those who require either systemic or high-dose inhaledglucocorticoid therapy

Elderly patient with new-onset asthma


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Lifestyle therapy :

smoking cessation, elevation of the head of the bed, avoiding large meals,avoiding food and drink at least three hours before retiring, not lying downwithin 2 hours after a meal and weight reduction.

A low-fat diet & away from foods that decrease the LES pressure : caffein,chocolate, mint, and alcohol

Avoided medication decrease LES pressure

Medical therapy PPIs : directly inhibit gastric secretion (the best therapy)

H2 antagonists : partially block gastric acid secretion

Antacids : symptomatic relief pH X pepsin Prokinetic : - improve esophageal contractility

- increase LES pressure- incrase gastric emptying

Surgical Nissen, Toupet, and Belsey fundoplication

Hill gastoplexy

Laparoscopy

Therapeutic Approach to GERD in Asthmatic


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PENATALAKSANAAN

1. Modifikasi gaya hidup

a. Hilangkan faktor resiko : stop rokok, me BB,

b. Hindari makanan potensi refluks : coklat, mint,alkohol, onions, kopi, cola, citrus fruits

c.

d. Hindari makan/minum sebelum tidur at least threehours before retiringe. Hindari high-fat meals that delay gastric emptying andfoods that lower LES pressure

Meninggikan kepala dan tempat tidur

menghindari pakaian ketat


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Stop Rokok & Menurunkan BB


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Avoid Tight Clothing


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Avoid Foods


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Do Not Lie Down for 2 hours After Eating


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PENATALAKSANAAN

2. Farmakologi : PPI, H2 antagonis, antacid dan prokinetik

3. Bedah antirefluks : medikamentosa gagal, hiatus hernia

4. Terapi endoskopi : radiofrekuensi, endoscopic suturing

5. Follow up


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Farmakologi


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PENATALAKSANAAN

1. Edukasi2. Menilai dan monitor berat asma secara

berkala

3. Identifikasi dan mengendalikan faktorpencetus

4. Merencanakan dan memberikan pengobatan

jangka panjang5. Menetapkan pengobatan pada serangan akut

6. Kontrol secara teratur

7. Pola hidup sehat


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STRATEGI PENGELOLAAN GERD

PPI (Dosis Standar)H2RA (Dosis Standar)

H2RA (Dosis Anti Refluks)

Pendekatan Step-Up Pendekatan Step-Down

Heartburn : rasa tidak nyaman sensasi panas atau perasaan


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Heartburn : rasa tidak nyaman, sensasi panas atau perasaan

terbakar dibawah/belakang dada (sternum), kadang-kadang

menjalar ke arah leher atau punggung (belakang).

It is commonly postpandrial and exacerbated by lying flat or

bending overRegurgitation : pergerakan kembali isi lambung (material refluks)

sampai esofagus atau faring yang menimbulkan keluhan sering

sendawa dan/atau mulut rasa asam atau pahit

This occurs in the absence of retching, which distinguishesit from vomitingWaterbrush : refleks sekresi saliva di mulut yang distimulasi oleh

asam di esofagus

lacks the bitter taste of acid and accumulates in the mouth,

rather coming from below up to the mouth

Dysphagia . This often manifest itself to the patient as a

sensation of food sticking in the retrosternal area. Difficulties with

swallowing related to reflux disease are often intermittent, when

they are probably related to reflux-related esophageal


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INHALASI


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INHALASIPEMBERIAN MEDIKASI LANGSUNG KE JALAN NAPAS

KELEBIHAN1. Lebih efektif untuk mencapai konsentrasi tinggi di

jalan napas

2. Efek sistemik minimal atau dihindarkan3. Beberapa obat hanya dapat diberikan melalui

inhalasi, tidak terabsopsi peroral (antikolinergik)

KEKURANGAN

1. Sulit koordinasikan 2 kegiatan (menekan inhaler danmenarik napas) dalam satu waktu

2. Perlu latihan berulang-ulang penderita trampil

Possible Approach to GERD in


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Possible Approach to GERD in

Asthmatics with Reflux Symptoms

Three month trial omeprazole 20 mg BID

Monitor PEF, asthma symptoms

Improved Not improved

Not GERD related

Maintenance Therapy

Consider Surgical Evaluationo Proton Pump Inhibitor - Confirm presence of GERD

o H2 Blockers (pH monitor, EGD)

o Prokinetic Agents - Absence of long stricture

(barium swallow, EGD)

- Hypotonic LESP (manometry)- Normal esophageal motility

(manometry, barium swallow)

Fundoplication


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Table-Medical Trials of GERD-Related Asthma

Source No.of

Patients

No. of Control

Subjects

Treatment Asthma Outcome

Kjellen et al 31 31 Antacids/alginic acid 54 % improved

Goodall et al 18 Placebo crossover Cimet 200 mg qid for 6 wk Increased PEFR &decreased asthma

symptoms in 75 %

Harper et al 15 - Ranit 150 mg bid for 8 wk Decreased symptoms &improved PFT results over

entire group

Nagel et al 15 Placebo crossover Ranit 450 mg/d for 1 wk No difference

Ekstrom et al 24 Placebo crossover Ranit 150 mg bid for 4 wk Mild decrease nocturnalsymptoms and decreased

MDI use

Depla et al 1 - OMZ 20 mg/d for 3 mo Complete relief of

symptoms

Ford et al 11 Placebo crossover OMZ 20 mg/d for 4 wk No difference

Meier et al 15 Placebo crossover OMZ 20 mg bid for 6 wk 29 % increased FEV1by 20 %

Harding et al 30 - OMZ 20-60 mg/d;documented acid suppression

73 % increased PEFR or

decreased symptoms by20 %


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UPPER GI SYMPTOMS

GERD-like symptoms Heartburn

Regurgitation

Dysphagia

Odynophagia

Waterbrush

Ulcer-like symptoms

Epigastric paint/discomfort

Dysmotility-like symptoms

Bloating

Nausea and vomiting

Early satiety

Excessive flatus


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Cause Direct

Mucosal Injury

Alendronate

Nonsteroidal anti-

inflammatory drugs

Potassium chloride

tabletsQuinidineTetracycline

Decrease LES Pressure

-adrenergic agonists-adrenergic antagonist

Anticholinergic

Calcium channel

blockers

Diazepam

Estrogens

Narcotics

Progesterone

Theophylline

Tricyclic antidepressants

Table 11-1 Medication that can cause GERD or esophagitis


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Table 11-2. Factors that can precipitate or exacerbate GERD symptoms

Medications (See table 11-1)

Foods

Caffeine

Chocolate

Peppermint

Alcohol (red wine pH = 3,25)

Carbonated beverages (cola pH = 2,75)

Citrus fruits (orange juice pH = 3,25)

Tomato-based produts (tomato juice pH = 3,25)

Vinegar (pH = 3,00)

Lifestyle factors

Weight gain

Smoking

Eating prior to recumbency


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Table 11-3. Alarm signs that necessitate further evaluation of

GERD

Dysphagia

Odynophagia

Weight loss

Gastrointestinal (GI) bleedingFamily history of upper GI tract cancer

Anemia

Advanced age

Does asthma cause GERD ?


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There is little controversy about the association between GER and asthma, but the

exact nature of the relationship is unclear

It the present study, asthma patients had a higher prevalence of GER symptoms and

greater need for antireflux medication than two otherwise similar control groups.

The proportions of asthmatics, with and without GER symptoms, taking -agonists,theophylline, ipratropium, and oral and inhaled corticosteroids were similar

suggesting that asthma medication is not an important determinant of GER

symptoms

Does Asthma Predispose Patients to Get GERD ?

Physiologic alterations associated with asthma and bronchodilator medications maypromote GERD

Hubert et al administered oral theophylline or placebo to asthmatics finding no difference in the numberof reflux episodes or total acid exposure time while pulmonary function improved

Sontag et al Asthmatic had significantly more reflux than normal control subjects. However, the74 asthmatic taking theophylline, -agonists, and/or prednisone had no more esophageal reflux

than the 30 asthmatics not receiving these medications

In conclusion, these data suggest that asthma should be treated aggresively withbronchodilator and anti-inflammatory agents; however, theophylline should be

used carefully in asthmatics with GERD


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STRATEGI PENGELOLAAN GERD

PPI (Dosis Standar)H2RA (Dosis Standar)

H2RA (Dosis Anti Refluks)

Pendekatan Step-Up Pendekatan Step-Down

Heartburn : rasa tidak nyaman, sensasi panas atau perasaan


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y , p p

terbakar dibawah/belakang dada (sternum), kadang-kadang

menjalar ke arah leher atau punggung (belakang).

It is commonly postpandrial and exacerbated by lying flat or

bending overRegurgitation : pergerakan kembali isi lambung (material refluks)

sampai esofagus atau faring yang menimbulkan keluhan sering

sendawa dan/atau mulut rasa asam atau pahit

This occurs in the absence of retching, which distinguishesit from vomitingWaterbrush : refleks sekresi saliva di mulut yang distimulasi oleh

asam di esofagus

lacks the bitter taste of acid and accumulates in the mouth,

rather coming from below up to the mouthDysphagia . This often manifest itself to the patient as a

sensation of food sticking in the retrosternal area. Difficulties with

swallowing related to reflux disease are often intermittent, when

they are probably related to reflux-related esophageal

V l M di t d R fl


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Vagal Mediated Reflex

Hiperaktivitas Bronkus

Micro Aspiration

Neurogenic Inflammation

Local Axonal Reflex

Infeksi

Alergen

Fisik

GERD

Psikis

Lingkungan

Keturunan

Obesity Fatty meal

Pregnancy Heavy meal

Tight Fitting garment Spicy food

Rapid eating behaviour Coffee, tea, onions

Reclining after eating Cigarette smoking

Emotional stress Medication

Larynx

Middle ear

Nasal

Oral

Pharynx/LarynxAirway

- Chronic cough

- Aspiration Pneumonia

ASMA

Medication

Hiatus Hernia

Hipervagal State

P Thorax AbdomenHiperinflation

Diafragma Mendatar

Asam Lambung

LES

Inspirasi

Penatalaksanaan serangan Asma di Rumah


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Penatalaksanaan serangan Asma di Rumah

Penilaian Berat Serangan

Klinis: gejala (batuk, sesak, mengi, dada terasa berat) yang bertambah

APE80%

prediksi/ nilai terbaik

-Lanjutkan agonis beta-2 inhalasi setiap 3 - 4 jam

untuk 24 48 jam

Alternatif: bronkodilator oral setiap 6 8 jam

-Steroid inhalasi diteruskan dengan dosis tinggi

(bila sedang menggunakan steroid inhalasi)

selama 2minggu, kmd kembali ke dosis

sebelumnya

Hubungi dokter

untuk instruksi

selanjutnya

Respon buruk

Gejala menetap atau bertambah

beratAPE


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Klasifikasi berat serangan asma akut

Gejala dan Tanda Berat Serangan Akut Keadaan Mengancam

JiwaRingan Sedang Berat

Sesak Napas Berjalan Berbicara Istirahat

Posisi Dapat tidur tenang Duduk Duduk membungkuk

Cara berbicara Satu kalimat Beberapa kata Kata demi kata

Kesadaran Mungkin gelisah Gelisah Gelisah Mengantuk, gelisah,

kesadaran menurun

Frekuensi napas 30x/menit

Nadi 120 Bradikardia

Pulsus paradoksus -

10mmHg

+/-

10-20mmHg

+

> 25mmHg

-

Kelelahan otot

Otot Bantu Napas dan

retraksi suprasternalMengi

-

Akhir ekspirasi paksa

+

Akhir ekspirasi

+

Inspirasi dan ekspirasi

Torakoabdominal

paradoksalSilent chest

APE > 80% 60-80% < 60%

PaO > 80mmHg 60-80mmHg < 60mmHg

PaCO < 45mmHg < 45mmHg > 45mmHg

SaCO > 95% 91-95% < 90%


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The Relationship Between GERD and Asthma

Many trigger and comorbid conditions asthma Been discussed for many years

Two disorders often occur together unclear

The prevalence of GERD in asthmatics : 34 89 % The Expert Panel Report 3 : Guidelines for the

Diagnosis and Management of Asthma GERDas a comorbid condition of asthma and

recommends medical management of GERD inappropriate patients

1892, Sir W Osler : severe paroxysm of asthmamay be induced by overloading the stomach, orby taking certain article of food.

Algoritme Penatalaksanaan GERD


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Algoritme Penatalaksanaan GERD

Pelayanan Kesehatan Lini Pertama

Gejala Khas GERD*Heartburn

*Regurgitasi

Gejala peringatan

Umur > 40 thn

Tanpa gejala peringatan

Umur >40 thn

Gejala menetap / berulang

Kekambuhan

Terapi empirik (PPI test)

Respons baik

Terapi minimal 4 minggu

On-demand therapy

Endoskopi


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Typical GERD symptoms

Alarn sign present Alarm signs absent

Lifestyle changes,OTC,antacids, H2RA prn

Lifestyle changes,

OTC,antacids, H2RA prn


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STEROID EFFECTS in ASTHMA with GERD


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Sebagian besar GERD mempunyai tonus LES yang normal transient LES relaxation (TLESR) : relaksasi LES bersifat spontan

dan berlangsung lebih kurang 5 detik tanpa didahului proses

menelan.Ada hubungannya dgn : - pengosongan lambung lambat dan

- dilatasi lambung

1. Refluks spontan pd saat relaksasi LES yang tidak adekuat

2. Aliran retrogad yang mendahului kembalinya tonus LES

setelah menelan

3. Meningkatnya tekanan intra abdomen

Mekanisme refluks gastroesofageal pada GERD


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Faktor-faktor dapat menurunkan tonus LES

1. Adanya hiatus hernia.

2. Panjang LES (makin pendek LES, makin rendah tonusnya)

3. Obat-obatan (antikolinergik, -adrenergik, teofilin, opiat dll)

4. Faktor hormonal. Selama kehamilan kadar progesteron me


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Alarm sign : BB menurun, anemia,hematemesis/melena, disfagia, odinofagia, Rx.

Keluarga Ca esofagus/lambung & umur 40 th


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MODIFIKASI GAYA HIDUP

1) Meninggikan posisi kepala pada saat tidur dan menghindari

makan sebelum tidur- menigkatkan bersihan asam selamatidur dan mencegah refluks asam lambung

2) Stop merokok dan alkohol menurunkan LES

3) Me konsumsi lemak dan mengurangi jumlah makanan

menimbulkan distensi lambung

4) Me BB dan hindari pakaian ketatme tekanan abdomen

5) Makanan/minuman merangsang sekresi asam lambung :

coklat, teh, kopi, mint & minuman bersoda

6) Jika mungkin hindari obat me tonus LES : anti kolinergik,teofilin, diazepam, opiat, antagonis kalsium, agonist beta

adrenergik, progesteron

GERD (gastroesophageal refluks disease)

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