gerd - nccp - kppik 2011 (hotel shangri la)

7/29/2019 Gerd - Nccp - Kppik 2011 (Hotel Shangri La)

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Non Cardiac Chest Pain (NCCP)Related to GERD

Dadang Makmun

Division of Gastroenterology Department of Internal Medicine

Medical Faculty University of Indonesia, Jakarta

(Jakarta March 12, 2011 - KPPIK FKUI )


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INTRODUCTION

GERD is the pathologic condition caused byeffortless movement of gastric contents tothe esophagus, including symptoms or signsreferable to the esophagus, pharynx, larynx

and respiratory tract esophagus as wellas extra esophagus manifestation severecomplication:

Stricture Barretts esophagus

Adenocarcinoma


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GERD is a condition which develops when the reflux

of stomach content causes troublesome symptoms

and / or complications

EsophagealSyndromes

Extra-esophageal

Syndromes

Symptomat ic

Syndromes

Typical Reflux

Syndrome

Reflux Chest

Pain Syndrome

Syndromes

with Esop hageal

Injury

Reflux Esophagitis

Reflux Stricture

Barretts Esophagus

Adenocarcinoma

Establ ished

Associat ions

Reflux Cough

Reflux Laryngitis

Reflux Asthma

Reflux Dental Eros.

ProposedAssoc ia t ions

Pharyngitis

Sinusitis

Idiopathic

Pulmonary Fibrosis

Recurrent Otitis

Media

Vakil N et al. Am J Gastroenterol 2006; in press

The Montral definition of GERD


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CLINICAL MANIFESTATION

Spectrum of Gastroesophageal Reflux Disease

Organ Types of Disease Manifestation

General Symptoms Belching, heartburn, regurgitation, chest pain,

dysphagia, pharyngeal soreness, hoarseness, coughing

Esophagus Erosion, ulcer, stricture, Barretts metaplasia,

adenocarcinoma

Throat Pharyngitis, laryngitis, sinusitis, aphonia, laryngeal

stenosis, cancer

Mouth Tooth decay, gingivitis

Lung Asthma, chronic obstructive pulmonary disease,pneumonia

Fass, 2004


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Kasus :

Ny. X 38 thn, karyawati sebuah bank nasional(supervisor) sejak satu bulan yang lalu seringmengeluh sakit dada bagian tengah, sepertiditusuk-tusuk, kadang2 rasa sakit tembus

sampai ke punggung. Pasien sering mengeluhrasa kembung, kadang2 jika sedang menelanmakanan seperti tertahan di dada bagiantengah.

Pasien sesekali mencoba minum obatpenghilang rasa sakit (pain killer) dari toko obatnamun tidak menolong, keluhan tetap adabahkan makin sering terasa


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Kasus : (lanjutan)

Karena kadang2 terasa kembung, pasiensering mencoba obat maag yang dijualbebas namun keluhan tidak banyak

berkurang. Pada pemeriksaan fisik: TD 120/80,

nadi:72x/menit, pernafasan normal.Conjunctiva tidak anemis, sclera tidak

ikterik. Pemeriksaan jantung, paru, abdomen dan

ekstremitas tidak ditemukan kelainan yang

nyata


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Kasus : (lanjutan)

Pertanyaan:

Apa diagnosis kerja pada pasien ini ?

Apa rencana penatalaksanaan selanjutnya ?


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Kasus : (lanjutan)

Hasil pemeriksaan penunjang yangdilakukan:

Lab: darah tepi, fungsi hati, fungsi ginjal sertagula darah dalam batas-batas normal.

Foto thoraks: cor dan pulmo tak tampakkelainan

EKG: dalam batas-batas normal

Pertanyaan:Apa diagnosis kerja pada pasien ini ? Pemeriksaan dan penatalaksanaan apa yang

harus dilakukan ?


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Kasus : (lanjutan)

Pasien dikonsulkan ke ahli penyakit jantung.Setelah dilakukan pemeriksaan yang memadai

disimpulkan bahwa tidak ada kelainan jantung.

Ultrasonografi menunjukkan bahwa organ2

intraabdomen (hepar, lien, kandung empedu,ginjal dan pankreas) dalam batas normal

Pemeriksaan endoskopi saluran cerna bagian

atas (esofagogastroduodenoskopi)menunjukkan adanya erosi/ulkus superficial

multipel yang memanjang didekat LES


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Kasus : (lanjutan)

Pertanyaan:Apa diagnosis pada pasien ini ?

Apa rencana pengobatan selanjutnya ?


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Impairedmucosaldefence

de Caestecker, BMJ2001; 323:7369.Johanson,Am J Med2000; 108(Suppl 4A): S99103.

salivary HCO3

Hiatus hernia

Impaired LES(smoking, fat, alcohol)

transient LES

relaxations

basal toneH+

PepsinBile and

pancreaticenzymes

esophageal

clearance of acid

(lying flat, alcohol,

coffee)

acid output

(smoking, coffee)

intragastric pressure

(obesity, lying flat)

bile reflux gastric emptying (fat)

Pathophysiology of GERD


13/28Orlando RC. Am J Gastroenterol 1996;91: 16926

Nerve

ending

Entry of acid into cells via the basolateralmembrane, leading to cell edema and necrosis

acid

pepsin

bicarbonate

Refluxed acid and pepsincauses pain and cell damage

Penetration of acid and pepsin allowscontact of acid with nerve endings


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Heartburn affects many aspects of everyday lifein adults with GERD

0%

20%

40%

60%

80%

100%

Enjoying

food

Eatingo

ut

Slee

p

Work

Family

activitie

s

Exercis

e

Socializing

Travelfor

pleasure

Intimacy/sex

Gardenin

g

Timewith

spouse

Business

travel

Hobbie

s

Playingwith

kids

Teamsports

Individuals affected (%)

n >130,000

Activity affected

Liker H et al. J Am Board Fam Pract 2005;18:393400


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Grade A esophagitis Grade B esophagitis

Grade C esophagitis Grade D esophagitis


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Barretts esophagus


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NCCP chest pain of esophageal origin

Defined as recurring angina-like substernal

chest pain of non cardiac origin

Overall prevalence of NCCP

23,1% in onepopulation base (Fass, 2004) inversely

associated with increasing age.

Squeezing or burning substernal chest pain,

which may radiate to the back, neck, arms

and jaws most of these patients are

evaluated initially by a cardiologist


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Different underlying mechanisms for noncardiac

chest pain


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The mechanism by which acid reflux causes

heartburn in some patients and chest pain in

others remainds poorly understood

The prevalence of erosive esophagitis inpatients with GERD-related NCCP has been

reported to be varied from 10-70% is likely to

be related to the different population


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The proton pump inhibitor (PPI) testwhy?

Readily available and at the disposal of primary

care physicians

Increases the role of primary care physicians in

evaluating and treating patients with spectrum ofGERD

Decreases patients discomfort-less invasive

tests

Offres significant cost saving


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The proton pump inhibitor test in patients with NCCP

Group(first

author)

Patients,n

Protonpump

inhibitor

Dose Cutoffsymptom

improvement,

%

Duration,days

Sensitivity,%

Young 30 Omeprazol 80

mg/day

75 1 80

Squillace 17 Omeprazol 80mg/day

50 1 69

Fass 37 Omeprazol 40 mg

AM/ 20

md PM

50 7 78

Fass 36 Rabeprazole 20 mg

AM/ 20mg PM

50 7 78

Fass 40 lansoprazole 60 mg

AM/ 30

mg PM

50 7 78

Fass, Dig Dis 18(1):20-26. 2000


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MANAGEMENT

Even though this condition is rarely fatal because of long-term complication (ulceration,

esophageal stricture, Barretts esophagus)

GERD requires adequate management

Management of GERD:

Lifestyle modification

Drugs

Surgical therapy

Endoscopic therapy


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Goals in the management of

GERD Provide complete (sufficient) relief from

heartburn and other symptoms

Heal underlying esophagitis

Maintain symptomatic and endoscopic

remission

Treat or, ideally, prevent complications

Dent et al 1999


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Reduce weight

Stop smoking

Avoid reflux-promotingagents (e.g. alcohol,

coffee, some foods)(not evidence based)

Elevate headof bed

Consider

alternatives toreflux-promoting drugs(e.g. theophylline,anticholinergics)

Modifications

Eat small meals,no late meals,

reduce fat

Lifestyle modifications for the

management of GERD


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? x2 daily PPI + H2RA

x2 daily PPI

x1 daily PPI

x1 daily PPI

Prokinetic + H2RA

Prokinetic*

Antacids + lifestyle

Antacids

Lifestyle

H2RA*OR

*no clear dose-response established

Highest efficacy

Lowest efficacy

Recommended

Should beabandoned

Current

guidelines

Mainstream options for therapy of

GERD

after Dent et al 2002


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Diagnosis and treatment flow chart for NCCP.

(PPI=proton pump inhibitor; GERD = gastroesophageal reflux disease, NCCP = noncardiac chest pain)

NCCP

Alarm Symptoms

PPI test (for 7 days)

Treat as GERD(at least double-dose PPI)

Taper down to lowerPPI dose that controls

symptoms

24-hour esophageal pHmonitoring (off therapy)

Treat as GERD

Upper endoscopy

Treat mucosal findings

Esophageal manometry

Spastic motility disorders:calcium channel blockers,nitrates, pain modulators

Achalasia: calcium channelblockers, nitrates, botulinum

toxin, pnuematic dilation,sugery

Pain modulators

Alarm symptoms: dysphagia,

odynophagia, Weight loss, anorexia,

anemia


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Thank You

gerd - nccp - kppik 2011 (hotel shangri la)

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