Gastro-esophageal Reflux Disease (GERD)
Introduction and Facts
Gastroesophageal reflux disease (GERD) is a weakening of the lower esophageal sphincter (LES) which results in reflux of stomach acid into the esophagus. The prevalence of GERD according to the 2008 Map of Digestive Disorders & Diseases in the United States, United Kingdom, Australia, China, Japan, Malaysia, and Singapore was 15%, 21%, 10.4%, 7.28%, 6.60%, 38.8%, and 1.6%. There is no data on GERD in Indonesia, but complaints similar to GERD are quite common in daily practice.
One of the problems for every health worker in primary health care centers is establishing a diagnosis and determining GERD therapy with limited diagnostic support tools. The definition of GERD according to the National Consensus for the Management of Gastroesophageal Reflux Disease in Indonesia in 2013 is a disorder in which gastric contents experience repeated reflux of gastric acid into the esophagus, causing disturbing symptoms and/or complications. GERD is a pathological condition due to reflux of gastric contents into the esophagus with various symptoms due to involvement of the esophagus, pharynx, larynx and airways.
Pathophysiology
GERD occurs due to an imbalance between the offensive and defensive factors of the esophageal defense system and gastric reflux materials. The defensive factors of the esophageal defense system are the LES, the esophageal clearance mechanism, and the esophageal epithelium. The LES is an angular anatomical structure that separates the esophagus from the stomach. Under normal circumstances, LES pressure will decrease during swallowing, resulting in antegrade flow from the esophagus to the stomach. In GERD, the function of the LES is impaired and causes retrograde flow from the stomach to the esophagus.
Disruption of LES function in GERD is caused by a decrease in LES pressure due to the use of drugs, food, hormonal factors, or structural abnormalities. While the offensive factors include increased gastric acid, gastric dilatation or gastric outlet obstruction, gastric distention and delayed gastric emptying, increased intragastric and intra-abdominal pressure. Some conditions that affect intra-abdominal pressure include pregnancy, obesity, and clothes that are too tight.
Clinical Symptoms and Complications
The typical signs and symptoms of GERD are regurgitation and heartburn. Regurgitation is a reflux condition that occurs shortly after eating, characterized by a sour and bitter taste on the tongue. Heartburn is a burning sensation in the epigastric area that can be accompanied by pain and tenderness. In layman's language, heartburn is often known as a burning sensation in the pit of the heart that is felt to the chest area. Both of these symptoms are generally felt after eating or lying down. Other symptoms of GERD are bloating, nausea, early satiety, belching, hypersalivation, dysphagia to odynophagia.
Dysphagia is usually the result of a stricture or malignancy of Barrett's esophagus. While odynophagia or pain when swallowing is generally due to severe ulceration or in cases of infection. Non-cardiac chest pain, chronic cough, asthma, and laryngitis are extraesophageal symptoms of patients with GERD.
Diagnosis
Based on the Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease issued by the American College of Gastroenterology in 1995 and revised in 2013, the diagnosis of GERD can be made based on:
1. Empirical Therapy
2. Use of Endoscopy
3. Ambulatory Reflux Monitoring
Esophageal manometry is recommended for preoperative evaluation to exclude rare motility disorders, such as achalasia or aperistalsis, which are associated with a disorder, such as scleroderma. The diagnosis of GERD was established based on classic symptoms from the history and filling out a questionnaire, as well as based on the results of the PPI (Proton Pump Inhibitor) therapy test.
The classic symptoms of GERD can also be assessed with the Gastroesophageal Reflux Disease Questionnaire GERD-Q. This diagnostic effort based on classic GERD symptoms is also supported by the National Consensus on the Management of Gastroesophageal Reflux Disease in Indonesia, Indonesian Gastroenterology Association, 2013. eat mainly fatty foods and large portions. An additional test for the diagnosis of GERD is a PPI therapy test.
PPI therapy trial is an empirical therapy by giving a double dose of PPI for 1-2 weeks without prior endoscopic examination. Indications for PPI therapy are patients with classic symptoms of GERD without alarm signs. Alarm signs include age >55 years, dysphagia, odynofasia, iron deficiency anemia, weight loss, and the presence of melena bleeding/hematemesis. If symptoms improve during use and worsen after treatment is discontinued, a diagnosis of GERD can be made.
Medication and Treatment
The goals of GERD treatment are to manage symptoms, repair mucosal damage, prevent recurrence, and prevent complications.
Based on the Guidelines for the Diagnosis and Management of Gastroesophageal Reflux Disease in 1995 and revised in 2013, GERD therapy can be done by:
1. Treatment Guideline I: Lifestyle Modification
2. Treatment Guideline II: Patient Directed Therapy
3. Treatment Guideline III: Acid Suppression
4. Treatment Guideline IV: Promotility Therapy
5. Treatment Guideline V: Maintenance Therapy
6. Treatment Guideline VI: Surgery Therapy
7. Treatment Guideline VII: Refractory.
Broadly speaking, the principle of GERD therapy in primary health care centers based on the Guidelines for the Diagnosis and management of Gastroesophageal Reflux Disease is to make lifestyle modifications and medical therapy for GERD. Lifestyle modification is a lifestyle arrangement that can be done by:
1. Lose weight if you are obese or maintain your body weight according to the ideal BMI
2. Elevate the head ± 15-20 cm / keep the head elevated when lying down
3. Have dinner at least 2-3 hours before going to bed
4. Avoid foods that can stimulate GERD such as chocolate, drinks containing caffeine, alcohol, and fatty foods - sour - spicy.
Medical therapy is therapy using drugs. PPI is one of the drugs for the treatment of GERD that has a similar effectiveness to surgical therapy. When compared with other drugs, PPIs have been shown to be the most effective in treating symptoms and curing esophagitis lesions. The PPIs include omeprazole 20 mg, pantoprazole 40 mg, lansoprazole 30 mg, esomeprazole 40 mg, and rabeprazole 20 mg. Single-dose PPIs are generally given in the morning before breakfast. While the double dose is given in the morning before breakfast and in the evening before dinner.
Reference: Saputera MD, Budianto W. Diagnosis dan Tatalaksana Gastroesophageal Reux Disease GERD di Pusat Pelayanan Kesehatan Primer. Cermin Dunia Kedokteran 2017;447:329-32.
