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  • 1. 2004 Consensus for Clinical Practice Guidelinefor the Management of Gastroesophageal Reflux Disease
  • 2. 2547ISBN 974-9716-98-1 : . : . : . : . : . : . . . . . . . . .. . . . .. . . 240/37 . . . 10700. 0-2866-3002-3 . 0-2412-53202
  • 3. Guideline for the management of GERD 5-10 (GastroesophagealReflux Disease, GERD) 5 2 10-15 dyspepsia heartburn heartburn typical atypi- cal GERD consensus , , , ENT, 3
  • 4. () .. 4
  • 5. Guideline for the management of GERD Guideline Algorithm for the Management of GERD Guideline reflux reflux GERD (quality of life) guideline algorithm algorithm Symptoms suggestive of GERD 1 2 No Alarm Yes Dysphagia 4 Odynophagia 3 Frequent vomiting Typical 7 Atypical GI bleed / anemia * Exclude other conditions Weight loss 5 LSM plus 8 LSM plus 10 Standard dose Symptom Double dose PPI 2 wks Symptom PPI 4 wks persist (consider 4-12 wks for persist atypical GERD)Symptom free 9 10 11 Stop Symptom Maintain Rx free for at least 4 wks Symptom EGD/ persist Re-evaluationRecurrent symptom Symptom improve 6 Maintenance therapy - On-demand/Intermittent Rx Alarm symptoms - Continuous therapy 5
  • 6. 1. Symptoms suggestive of GERD GERD refluxate (content ) GERD heartburn () / regurgitation () water brash (), chest pain ( ), dysphagia () odynophagia () epigastric pain GERD epigastric pain dyspepsia 2. Alarm symptoms ( ) , (odynophagia), , (Esophagogastroduodenoscopy; EGD) 3. Typical symptoms of GERD GERD heart- burn / regurgitation4. Atypical symptoms of GERD GERD GERD 4.1 retrosternal chest pain 6
  • 7. Guideline for the management of GERD ( ) 4.2 chronic cough, hemopty- sis, bronchitis, bronchiectasis recurrent pneumonia 4.3 hoarseness, throat clear- ing, chronic laryngitis, otalgia, sinusitis otitis media 4.4 , 5. lifestyle modification (LSM) - 15 . 6-8 - - - - - 2 . - - an- ticholinergics, theophylline, tricyclic antidepressants, cal- cium channel blockers, -adrenergic agonists, alendronate - - 7
  • 8. proton pump inhibitors (PPIs) equiva- lent dose Omeprazole 20 mg daily Lansoprazole 30 mg daily Pantoprazole 40 mg daily Rabeprazole 20 mg daily Esomeprazole 40 mg daily PPI H2-receptorantagonist (H2RA) cimetidine 800 mg, ranitidine 300 mg,famotidine 40 mg 6. Maintenance treatment / On-demand/intermittent therapy / Continuous treatment symptomatic GERD On-demand/intermittent therapy Continuous treatment on-demand therapy 24 . intermittent therapy 1-2 continuous treatment continuous treatment step down strategy 8
  • 9. Guideline for the management of GERDHighest efficacy Double dose PPI + Bed time H2RA Double dose PPI Full (standard) dose PPI Half dose PPI Standard dose H2RA + ProkineticsLowest efficacy Standard dose H2RA or Prokinetics7. atypical GERD GERD 8. 8.1 Extraesophageal GERD PPI 2 () 4-12 non- cardiac chest pain 4-8 12 8.2 typical GERD standard dose PPI 2 PPI 4-12 9. PPI double dose 4 extraesophageal GERD long term main- tenance therapy on- demand / intermittent therapy 9
  • 10. 10. PPI double dose 12 (symptom persist) EGD 11. EGD 11.1 alarm symptoms / GERD , 11.2 (severe esophagitis) GERD Barretts esophagus 11.3 11 Endoscopy 15 16 Normal Mild to moderate Severe Esophagitis Non-GERD esophagitis or Barretts diagnosis 12 Re-assessment 13 LSM/Intensify Treatment (1) If GERD still considered symptom persist Treat 14 appropriately Ambulatory pH +GERD 17 -GERD - LSM/Intensify Treatment ( 2 ) - Continue long term maintenance Rx Seek other - or Consider anti-reflux procedures diagnosis10
  • 11. Guideline for the management of GERD12. 13. GERD lifestyle modification (15 .) (Intensify treatment 1) 13.1 13.2 H2RA (ranitidine 150 mg cimetidine 400 mg) noctur- nal acid breakthrough 13.3 PPI14. ambulatory pH monitoring LSM 13 ambulatory pH moni- toring 15. Mild to moderate esophagitis Savary-Miller grade 1-3 grade A B Los Ange- les classification16. Severe esophagitis Savary-Miller classifica- tion grade 4-5 grade C D Los Angeles classification. Barretts esophagus endoscopic ex- 11
  • 12. amination histology 17. 13 [LSM/Intensify treatment (1)] H2RA 2 ranitidine 300 mg mild moderate disease GERD on-demand in- termittent therapy (long term maintenance therapy) step down strategy severe esophagitis (long term maintenance therapy) Barretts esophagus PPI endoscopy surveillance 1-3 ( American College of Gastroenterology) 1. 2. 3. 4. 12