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Guideline gerd

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Guideline gerd

  1. 1. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕπ„πª√–‡∑»‰∑¬ ®“°°“√ª√–™ÿ¡ 2004 Consensus for Clinical Practice Guidelinefor the Management of Gastroesophageal Reflux Disease ®—¥∑”‚¥¬ ™¡√¡‚¡∏‘≈‘µ’È·Ààߪ√–‡∑»‰∑¬  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬
  2. 2. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕπ„πª√–‡∑»‰∑¬‚¥¬™¡√¡‚¡∏‘≈‘µ’È·Ààߪ√–‡∑»‰∑¬ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬æ‘¡æå§√—Èß·√° ∏—𫓧¡ 2547ISBN 974-9716-98-1§≥–ºŸâ®—¥∑”∑’˪√÷°…“ : πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ : πæ. ‘π Õπÿ√“…Ø√å : πæ.æ‘π® °ÿ≈≈–«≥‘™¬å ‘ : æ≠.«—π¥’ «√“«‘∑¬åª√–∏“π : πæ.Õÿ¥¡ §™‘π∑√‡≈¢“πÿ°“√ : πæ. ¡™“¬ ≈’≈“°ÿ»≈«ß»å°√√¡°“√ πæ.°‘µµ‘ ®—π∑√å‡≈‘»ƒ∑∏‘Ï æ≠.‚©¡»√’ ‚¶…‘µ™—¬«—≤πå æ≠.∫ÿ…∫“ «‘«—≤π凫§‘π πæ.ª√–æ—π∏å Õà“π‡ª√◊ËÕß æ≠.«‚√™“ ¡À“™—¬ æ∑.«“π‘™ ªî¬π‘√π¥√å — πæ.«‘∑Ÿ√ ™‘π «à“ß«—≤π°ÿ≈ πÕ.πæ.«‘≠êŸ ®—π∑√ ÿπ∑√°ÿ≈ πæ.»µ«√√… ∑Õß «— ¥‘Ï πæ. ÿ‡∑æ °≈™“≠«‘∑¬å πæ.‡ ° ‘µ ‚Õ ∂“°ÿ≈ æÕ.πæ. ÿ√æ≈  ÿ√“ߧå»√’√—∞ æ≠. ÿæ√ µ√’æß…å°√ÿ≥“ πæ. ÿ√‘¬– ®—°°–æ“°ÕÕ°·∫∫·≈–®—¥∑”√Ÿª‡≈à¡‚¥¬∫√‘…—∑ ¬Ÿ‡π’ˬπ §√’‡Õ™—Ëπ ®”°—¥240/37 ∂. ®√—≠ π‘∑«ß»å Õ.∫“ß°Õ°πâÕ¬ °∑¡. 10700‚∑√. 0-2866-3002-3 ·øì°´å. 0-2412-53202
  3. 3. Guideline for the management of GERD §”π” „π™à«ß 5-10 ªï∑’˺à“π¡“ ‚√§°√¥‰À≈¬âÕπ (GastroesophagealReflux Disease, GERD) ‡ªìπ‚√§∑’Ëæ∫‰¥â∫àÕ¬¡“°¢÷Èπ„π¿Ÿ¡‘¿“§‡Õ‡™’¬√«¡∑—Èߪ√–‡∑»‰∑¬ ‚¥¬„π™à«ß 5 ªïÀ≈—ßæ∫¡’§«“¡™ÿ°¢Õß‚√§°√¥‰À≈¬âÕπ„πª√–‡∑»‰∑¬‡æ‘Ë¡¢÷Èπª√–¡“≥ 2 ‡∑à“ §◊Õæ∫¡’§«“¡™ÿ°ª√–¡“≥√âÕ¬≈– 10-15 ¢ÕߺŸâªÉ«¬∑’Ë¡“¥â«¬Õ“°“√ dyspepsia ‚√§°√¥‰À≈¬âÕπ‡ªìπ‚√§∑’Ë«‘π‘®©—¬‰¥â§àÕπ¢â“߬“° ‡π◊ËÕß®“°Õ“»—¬°“√´—°ª√–«—µ‘‡ªì𠔧—≠ Õ“°“√®”‡æ“–¢Õß‚√§π’ȧ◊Õ heartburn ´÷Ë߉¡à¡’§”·ª≈‡ªìπ¿“…“‰∑¬‚¥¬µ√ß·≈–¬—ß¡’§«“¡‡¢â“„®∑’·µ°µà“ß°—π„π°“√ ◊Õ§«“¡À¡“¬¢Õߧ”«à“ heartburn ‚¥¬ Ë Ë‡©æ“–„πª√–™“™π∑—Ë«‰ª ·≈–‚√§π’Ȭ—߉¡à¡’°“√ ◊∫§âπ„¥∑’Ë®”‡æ“–∑’Ë®–™à«¬„π°“√«‘π®©—¬ πÕ°®“°π’≈°…≥–∑“ߧ≈‘π°¡’∑ß∑’‡ªìπ typical ·≈– atypi- ‘ È— ‘ È— Ëcal GERD ·¡â „πªí®®ÿ∫—π®–¡’¬“∑’Ë „Àâº≈„π°“√—°…“§àÕπ¢â“ߥ’·µà≈—°…≥–°“√¥”‡π‘π‚√§¡—°‡√◊ÈÕ√—ß·≈–‡ªìπÊÀ“¬Ê πÕ°®“°π’È „πºŸâªÉ«¬∑’ˇªìππ“π‡ªìπ ‘∫ªï∫“ß√“¬Õ“®π”‰ª Ÿà°“√‡°‘¥¡–‡√ÁߢÕßÀ≈Õ¥Õ“À“√‰¥âÕ’°¥â«¬ ™¡√¡‚¡∏‘≈‘µ’È·Ààߪ√–‡∑»‰∑¬ ¿“¬„µâ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ ‰¥â ‡ ≈Á ß ‡ÀÁ 𠧫“¡ ”§— ≠ „π°“√∑’Ë · æ∑¬å ® – “¡“√∂„Àâ ° “√«‘π‘®©—¬·≈–√—°…“√«¡∑—Èß°“√ª√–‡¡‘π·≈–µ‘¥µ“¡ºŸâªÉ«¬‚√§°√¥‰À≈¬âÕπ‰¥âÕ¬à“ß∂Ÿ°µâÕß ‡À¡“– ¡ ®÷߉¥â®—¥°“√ª√–™ÿ¡ consensus ‡æ◊ËÕ®—¥∑”·π«∑“ß°“√«‘π‘®©—¬·≈–¥Ÿ·≈√—°…“‚√§°√¥‰À≈¬âÕπ„πª√–‡∑»‰∑¬¢÷Èπ ‚¥¬„Àâ·æ∑¬å∑’ËÕ¬Ÿà „π‚√ß欓∫“≈∑ÿ°√–¥—∫ “¡“√∂π”·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“π’È ‰ªªØ‘∫—µ‘‰¥â®√‘ß °“√ª√–™ÿ¡¥—ß°≈à“«¡’ºŸâ‡¢â“√à«¡ª√–™ÿ¡ª√–°Õ∫¥â«¬Õ“¬ÿ√·æ∑¬å¥â“π√–∫∫∑“ߥ‘πÕ“À“√, »—≈¬·æ∑¬å, ·æ∑¬åºŸâ‡™’ˬ«™“≠¥â“π√–∫∫°“√À“¬„®, ·æ∑¬åºŸâ‡™’ˬ«™“≠¥â“π ENT, Õ“¬ÿ√·æ∑¬å∑—Ë«‰ª ·≈–·æ∑¬å‡«™ªØ‘∫—µ‘∑—Ë«‰ª ¡“√à«¡°—π„À⧫“¡‡ÀÁπ Õ¿‘ª√“¬·≈– √ÿª‡ªìπ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕππ’È¢÷Èπ  ¡“§¡®–‰¥â¡’°“√¥”‡π‘π°“√·®°®à“¬·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“π’È „Àâ·°à·æ∑¬å∑—Ë«ª√–‡∑» 3
  4. 4. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬√«¡∑—Èß®–¡’°“√µ‘¥µ“¡ª√–‡¡‘πº≈ ·≈–ª√—∫ª√ÿß„Àâ‡À¡“– ¡¬‘Ëߢ÷ÈπµàÕ‰ª  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬¢Õ¢Õ∫§ÿ≥·æ∑¬å∑ÿ°∑à“π∑’Ë ‰¥â ≈–‡«≈“𔧫“¡√Ÿâ·≈–ª√– ∫°“√≥å¡“√à«¡„π°“√®—¥∑”·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕπ„πª√–‡∑»‰∑¬π’È ·≈–¢Õ¢Õ∫§ÿ≥ ∫√‘…—∑ ·Õ µ√Ⓡ´π‡π°â“ (ª√–‡∑»‰∑¬) ®”°—¥ ∑’˙૬ π—∫ πÿπ°“√®—¥°“√ª√–™ÿ¡‚¥¬‰¡à¡’‡ß◊ËÕπ‰¢„¥Ê∑”„Àâß“π ”‡√Á®≈ÿ≈à«ß‰ª‰¥â¥â«¬¥’ ¡§«“¡¡ÿàßÀ¡“¬ √».πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ 𓬰 ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬4
  5. 5. Guideline for the management of GERD Guideline Algorithm for the Management of GERD Guideline 𒮥∑”¢÷π‡æ◊ՙ૬·æ∑¬å„π°“√¥Ÿ·≈√—°…“ºŸª«¬∑’¡ª≠À“ È— È Ë â É Ë’ í reflux ·≈–¿“«–·∑√°´âÕπ∑’ˇ°‘¥®“° reflux ‚¥¬„Àâæ‘®“√≥“„™â°—∫ºŸâªÉ«¬ GERD ∑’Ë¡’Õ“°“√®π¡’ªí≠À“µàÕ§ÿ≥¿“æ¢Õß™’«‘µ (quality of life) °“√Õ∏‘∫“¬ guideline ®–‡ªìπ‰ªµ“¡ algorithm ‚¥¬µ—«‡≈¢∑’Ë °”°—∫„π·µà≈– à«π¢Õß algorithm ®–µ√ß°—∫§”∫√√¬“¬„π·µà≈–À—«¢âÕ Symptoms suggestive of GERD 1 2 No Alarm Yes ë Dysphagia 4 ë Odynophagia 3 ë Frequent vomiting Typical 7 Atypical ë GI bleed / anemia * Exclude other conditions ë 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. 6. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬1. Symptoms suggestive of GERD 𑬓¡¢Õß GERD À¡“¬∂÷ß‚√§∑’ˇ°‘¥®“°§«“¡º‘¥ª°µ‘∑’ˇ√◊ÈÕ√—ß∑’Ë ‡°’ˬ«¢âÕß°—∫°“√∑’Ë¡’ refluxate (content Õ–‰√°Á ‰¥â∑’ËÕ¬Ÿà „π°√–‡æ“– Õ“À“√) ‰À≈¬âÕπ¢÷Èπ¡“ ŸàÀ≈Õ¥Õ“À“√ ´÷ËßÕ“®®–¡’À√◊Õ‰¡à¡’√àÕß√Õ¬ ¢Õß°“√Õ—°‡ ∫¢ÕßÀ≈Õ¥Õ“À“√°Á ‰¥â ‚¥¬Õ“°“√∑’Ë∫àß™’È«à“ºŸâªÉ«¬πà“®– ‡ªìπ‚√§ GERD ª√–°Õ∫¥â«¬ heartburn (Õ“°“√· ∫¬Õ¥Õ°) ·≈–/ À√◊Õ regurgitation (¢¬âÕπÀ√◊Õ ”√Õ°) ‡ªì𠔧—≠ πÕ°®“°π’ÈÕ“® æ∫Õ“°“√Õ◊ËπÊ Õ’°‰¥â ‡™àπ water brash (πÈ”≈“¬ Õ), chest pain (‡®Á∫ Àπâ“Õ°), dysphagia (°≈◊π≈”∫“°) ·≈– odynophagia (°≈◊π‡®Á∫) ‡ªìπµâπ  ”À√—∫Õ“°“√ epigastric pain ‰¡à∂◊Õ«à“‡ªìπÕ“°“√®”‡æ“–¢Õß GERD ¥—ßπ—ÈπÀ“°ºŸâªÉ«¬¡’Õ“°“√ epigastric pain Õ¬à“߇¥’¬« „Àâ æ‘®“√≥“¥Ÿ·≈ºŸâªÉ«¬·∫∫ dyspepsia ·∑π2. Alarm symptoms ºŸâ ªÉ « ¬∑’Ë ¡’ Õ “°“√¥— ß µà Õ ‰ªπ’È (´÷Ë ß ∂◊ Õ «à “ ‡ªì π Õ“°“√‡µ◊ Õ π À√◊ Õ  —≠≠“≥Õ—πµ√“¬) Õ“∑‘ °≈◊π≈”∫“°, °≈◊π‡®Á∫ (odynophagia), Õ“ ‡®’¬π∫àÕ¬Ê À√◊Õ¡’ª√–«—µÕ“‡®’¬π‡ªìπ‡≈◊Õ¥ À√◊Õ¡’Õ“°“√´’¥, πÈ”Àπ—°≈¥ ‘ À√◊Õ¡’ ‰¢â §«√∑”°“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡∑—π∑’ ¥â«¬°“√ àÕß°≈âÕßµ√«®∑“ß ‡¥‘πÕ“À“√ à«πµâπ (Esophagogastroduodenoscopy; EGD) À√◊Õ °“√µ√«®Õ◊ËπÊ∑’ˇÀ¡“– ¡3. Typical symptoms of GERD À¡“¬∂÷ßÕ“°“√®”‡æ“–∑’ËÀ“°ºŸâªÉ«¬¡’ Õ“°“√¥ß°≈“«„À§¥«“ºª«¬π“®–‡ªπ GERD Õ“°“√¥ß°≈“« §Õ heart- — à â ‘ à Ÿâ É à ì — à ◊ burn ·≈–/À√◊Õ regurgitation4. Atypical symptoms of GERD §◊ÕÕ“°“√∑’Ë ‰¡à®”‡æ“–«à“®–‡ªìπ‚√§ GERD ·µà‡ªìπÕ“°“√∑’ËÕ“® ‡ªìπº≈¡“®“°‚√§ GERD ‰¥â·°à 4.1 Õ“°“√∑‡°¬«¢Õß°∫À≈Õ¥Õ“À“√ ‡™π retrosternal chest pain ’Ë ’Ë â — à6
  7. 7. Guideline for the management of GERD (∑—Èßπ’ȵâÕ߉¥â√—∫°“√µ√«®·≈â« «à“‰¡à‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥À—«„®) 4.2 Õ“°“√∑“ß√–∫∫‡¥‘πÀ“¬„® ‡™àπ chronic cough, hemopty- sis, bronchitis, bronchiectasis ·≈– recurrent pneumonia 4.3 Õ“°“√∑“ß√–∫∫ ÀŸ §Õ ®¡Ÿ° ‡™àπ hoarseness, throat clear- ing, chronic laryngitis, otalgia, sinusitis À√◊Õ otitis media ‡ªìπµâπ 4.4 Õ“°“√Õ◊ËπÊ ‡™àπ øíπºÿ, ª“°¡’°≈‘Ëπ5. °“√√—°…“¥â«¬ lifestyle modification (LSM) ‡ªìπ°“√·π–π”«‘∏’ªØ‘∫—µ‘µ—« ·≈–§«√°√–∑”„πºŸâªÉ«¬∑ÿ°√“¬ ´÷Ëß ª√–°Õ∫¥â«¬ - °“√πÕπ‡µ’¬ß∑’ˬ°»’√…–„À⠟ߢ÷Èπ 15 ´¡. À√◊Õ 6-8 π‘È«øÿµ ‚¥¬ À≈’°‡≈’ˬ߰“√„™â‡µ’¬ßπÈ” - °“√πÕπ„π∑à“µ–·§ß´â“¬ - °“√ª√—∫惵‘°√√¡°“√°‘πÕ“À“√ „Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·µà≈– √“¬ ‚¥¬æ‘®“√≥“«à“¡’§«“¡ —¡æ—π∏å°∫Õ“°“√∑’‡ªìπÀ√◊Õ‰¡à ‡™àπ — Ë - À≈’°‡≈’ˬßÕ“À“√¡—π¡“°Ê - À≈’°‡≈’ˬßÕ“À“√∑’Ë°√–µÿâπ„Àâ¡’Õ“°“√ ‡™àπ °“·ø ™ÁÕ§‚°·≈µ Õ“À“√∑’Ë¡’√ ‡ª√’Ȭ«®—¥ ‡§√◊ËÕߥ◊Ë¡·Õ≈°ÕŒÕ≈å À√◊ÕπȔ՗¥≈¡ Õ“À“√∑’Ë¡’ à«πª√–°Õ∫¢Õß¡–‡¢◊Õ‡∑» Õ“À“√ª√–‡¿∑¡‘Èπµå - À≈’°‡≈’ˬ߰“√πÕπÀ≈—ß°‘πÕ“À“√Õ¬à“ßπâÕ¬ 2 ™¡. - À≈’°‡≈’ˬ߰“√°‘πÕ“À“√ª√‘¡“≥¡“°Ê „πÀπ÷Ëß¡◊ÈÕ - À≈’°‡≈’ˬ߬“∫“ß™π‘¥∑’ËÕ“®¡’º≈µàÕÀŸ√Ÿ¥¢ÕßÀ≈Õ¥Õ“À“√ ‡™àπ an- ticholinergics, theophylline, tricyclic antidepressants, cal- cium channel blockers, β-adrenergic agonists, alendronate ‡ªìπµâπ - ߥÀ√◊Õ≈¥°“√ Ÿ∫∫ÿÀ√’Ë - ≈¥πÈ”Àπ—° À“°¡’¿“«–Õâ«π 7
  8. 8. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ ¬“ proton pump inhibitors (PPIs) ¢π“¥¡“µ√∞“π ∑’ˇªìπ equiva- lent dose ª√–°Õ∫¥â«¬ Omeprazole 20 mg daily Lansoprazole 30 mg daily Pantoprazole 40 mg daily Rabeprazole 20 mg daily Esomeprazole 40 mg daily „π°√≥’∑’Ë ‰¡à “¡“√∂„™â PPI ‰¥â Õ“®æ‘®“√≥“„™â H2-receptorantagonist (H2RA) ‡™àπ cimetidine 800 mg, ranitidine 300 mg,famotidine 40 mg µàÕ«—π ·∑π‰¥â6. Maintenance treatment / On-demand/intermittent therapy / Continuous treatment ®ÿ¥¡ÿàßÀ¡“¬¢Õß°“√√—°…“ºŸâªÉ«¬∑’ˇªìπ symptomatic GERD §◊Õ °“√§«∫§ÿ¡Õ“°“√„À⺟âªÉ«¬ ∫“¬¥’‰ªµ≈Õ¥ ®÷ßµâÕߥŸ·≈√–¬–¬“« °“√ √—°…“„π√–¬–¬“«Õ“®‡ªìπ·∫∫ On-demand/intermittent therapy À√◊Õ Continuous treatment °“√√—°…“·∫∫ on-demand therapy ‡ªìπ°“√√—°…“„π°√≥’∑’˺Ÿâ ªÉ«¬°≈—∫¡“¡’Õ“°“√Õ’°À≈—ß®“°∑’ËÀ“¬·≈â« ‚¥¬„À⺟âªÉ«¬°‘𬓄π™à«ß √–¬–‡«≈“∑’Ë¡’Õ“°“√µ‘¥µàÕ°—π·≈–À¬ÿ¥¬“‡¡◊ËÕ‰¡à¡’Õ“°“√·≈⫇ªìπ‡«≈“ Õ¬à“ßπâÕ¬ 24 ™¡.  à«π intermittent therapy ‡ªìπ°“√√—°…“‚¥¬ „À⬓„π¢π“¥∑’Ë “¡“√∂§«∫§ÿ¡Õ“°“√ºŸâªÉ«¬‰¥â‡ªìπ™à«ß√–¬–‡«≈“ —ÈπÊ ‡™àπ 1-2  —ª¥“Àå·≈â«À¬ÿ¥¬“  ”À√—∫ continuous treatment ‡ªìπ°“√ √—°…“‚¥¬„À⬓µàÕ‡π◊ËÕ߇ªìπ√–¬–‡«≈“π“π ‚¥¬æ‘®“√≥“„™â „πºŸâªÉ«¬∑’Ë ‰¡ “¡“√∂À¬¥¬“‰¥‡πÕß®“°¬ß§ß¡Õ“°“√µ≈Õ¥ À√Õ Õ“°“√¥¢π ·µà à ÿ â Ë◊ — ’ ◊ ’ È÷ ¬—߉¡àÀ“¬¢“¥ √–¬–‡«≈“°“√°‘π¬“Õ“®π“π‡ªìπ‡¥◊Õπ®π∂÷ßÀ≈“¬ªï‰¥â „π°√≥’ continuous treatment Õ“®æ‘®“√≥“„™â step down strategy ¥—ßπ’È8
  9. 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. ºŸâªÉ«¬∑’Ë¡’Õ“°“√atypical GERD §«√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ„Àâ·πà„®«à“ ‰¡à¡’§«“¡º‘¥ª°µ‘Õ◊Ëπ °àÕπ∑’Ë®– √ÿª«à“ºŸâªÉ«¬‡ªìπ GERD ‡™àπ ºŸâªÉ«¬ ∑’Ë¡“¥â«¬‡ ’¬ß·À∫ §«√ª√÷°…“·æ∑¬å∑“ß ÀŸ §Õ ®¡Ÿ° ºŸâªÉ«¬∑’Ë¡“¥â«¬ Õ“°“√·πàπÀ√◊Õ‡®Á∫Àπâ“Õ° §«√ª√÷°…“·æ∑¬åºŸâ‡™’ˬ«™“≠‚√§À—«„® ‡ªìπµâπ8. 8.1 „π°√≥’∑’˺ŸâªÉ«¬‡ªìπ Extraesophageal GERD °“√√—°…“„Àâ ∂Õ«“ºª«¬°≈¡π‡ªπºª«¬∑¡§«“¡√π·√߮߷π–π”„Àâ„™¬“ PPI ◊ à Ÿâ É ÿà ’È ì Ÿâ É ’Ë ’ ÿ ÷ â „π¢π“¥«—π≈– 2 §√—È߇ªìπÀ≈—° („Àâ°àÕπÕ“À“√‡™â“·≈–‡¬Áπ) ‡ªì𠇫≈“ 4-12  ª¥“Àå„π‡∫Õßµπ  ”À√∫ non- cardiac chest pain — È◊ â — °“√„À⬓‡ªìπ√–¬–‡«≈“ 4-8  —ª¥“ÀåÕ“®®–‡æ’¬ßæÕ ”À√—∫°“√ √—°…“ „π¢≥–∑’Ë°≈ÿà¡Õ◊Ëπ¡’·π«‚πâ¡∑’Ë®–µâÕß„À⬓‡ªìπ‡«≈“π“π¢÷Èπ ®π∂÷ß 12  —ª¥“Àå 8.2 ºŸâªÉ«¬∑’Ë¡’Õ“°“√ typical GERD ∑’ËÕ“°“√‰¡à¥’¢÷ÈπÀ≈—ß®“°‰¥â¬“„π ¢π“¥ standard dose ¢Õß PPI „Àâæ‘®“√≥“‡æ‘Ë¡¬“‡ªìπ 2 ‡∑à“ °≈à“«§◊Õ„Àâ PPI ‡™â“‡¬Á𠇪ìπ‡«≈“Õ’° 4-12  —ª¥“Àå°àÕπ®– æ‘®“√≥“«à“°“√√—°…“π—Èπ‰¡à ‰¥âº≈9. ºŸâªÉ«¬∑’˵Õ∫ πÕßµàÕ°“√„À⬓ PPI „π¢π“¥ double dose §«√„Àâ ¬“µàÕ‡ªìπ‡«≈“Õ¬à“ßπâÕ¬ 4  —ª¥“Àå „π∫“ß°√≥’ºŸâªÉ«¬Õ“®µÕ∫ πÕß ¥’ ® π‰¡à ¡’ Õ “°“√°Á æ‘ ® “√≥“„Àâ À ¬ÿ ¥ ¬“‰¥â ¢≥–∑’Ë ° ≈ÿà ¡ ∑’Ë ‡ ªì π extraesophageal GERD Õ“®®–µÕß„À¬“‡ªπ·∫∫ long term main- â â ì tenance therapy À√◊Õ„π∫“ß√“¬Õ“®æ‘®“√≥“„Àâ°“√√—°…“·∫∫ on- demand ·≈–/À√◊Õ intermittent therapy ‰¥â 9
  10. 10. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬10. ºŸâªÉ«¬∑’ˬ—ߧߡ’Õ“°“√Õ¬Ÿà·¡â«à“®–‰¥â√—∫¬“ PPI „π¢π“¥ double dose ‡ªìπ‡«≈“ 12  —ª¥“Àå·≈â« (symptom persist) ·π–π”«à“§«√‰¥â√—∫ °“√µ√«®§âπ‡æ‘Ë¡‡µ‘¡¥â«¬°“√∑” EGD À√◊Õ„Àâª√–‡¡‘πÕ“°“√¢ÕߺŸâ ªÉ«¬„À¡à·≈–∑”°“√ ◊∫§âπ‡æ‘Ë¡‡µ‘¡µàÕ‰ª11. EGD §«√‰¥â√—∫°“√µ√«®„π°√≥’µàÕ‰ªπ’È 11.1 ºŸâªÉ«¬∑’Ë¡’ alarm symptoms ·≈–/À√◊Õ ß —¬¡’ ‚√§Õ◊ËπÊ ∑’Ë ‰¡à „™à GERD ‡™π‚√§·º≈„π°√–‡æ“–Õ“À“√, ¡–‡√ß„π°√–‡æ“–Õ“À“√ à Á œ≈œ ‡ªìπµâπ 11.2 ºŸâªÉ«¬∑’Ë —ππ‘…∞“π«à“Õ“®¡’À≈Õ¥Õ“À“√Õ—°‡ ∫√ÿπ·√ß (severe esophagitis) À√◊Õ¡’¿“«–·∑√°´âÕπ¢Õß GERD ‡™àπ Barrettûs esophagus 11.3 ºŸâªÉ«¬∑’ˬ—ߧߡ’Õ“°“√Õ¬Ÿàµ≈Õ¥¢≥–∑’Ë ‰¥â√—∫°“√√—°…“À√◊Õ‰¡àµÕ∫  πÕßµàÕ°“√√—°…“ 11 Endoscopy 15 16 Normal Mild to moderate Severe Esophagitis Non-GERD esophagitis or Barrettûs 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. 11. Guideline for the management of GERD12. ºŸâªÉ«¬∑’Ë ‰¥â√—∫°“√ àÕß°≈âÕß·≈â« ‰¡àæ∫§«“¡º‘¥ª°µ‘ §«√‰¥â√—∫°“√ ª√–‡¡‘π´È” ‚¥¬°“√´—°ª√–«—µ‘·≈–µ√«®√à“ß°“¬Õ¬à“ß≈–‡Õ’¬¥13. „π°√≥’∑’ˬ—ß ß —¬«à“ºŸâªÉ«¬‡ªìπ GERD ∑—ÈßÊ∑’Ë°“√ àÕß°≈âÕߪ°µ‘ °“√ √—°…“¥â«¬ lifestyle modification ∂◊Õ‡ªìπÀ—«„® ”§—≠∑’˵âÕ߇πâπ°—∫ºŸâ ªÉ«¬ Õ“∑‘°“√πÕπ¬°»’√…– Ÿß®“°æ◊Èπ (15 ´¡.) ‰¡à§«√„Àâ „™â‡µ’¬ßπÈ” ·≈–·π–π”„ÀâπÕπµ–·§ß´â“¬Õ“®™à«¬„À⺟âªÉ«¬Õ“°“√¥’¢÷Èπ‰¥â πÕ°®“°π—Èπ§«√∑∫∑«π°“√„™â¬“Õ¬à“ß≈–‡Õ’¬¥ (Intensify treatment 1) ¥ßπÈ’ — 13.1 ´°ª√–«µ°“√°π¬“¢Õߺª«¬„À·πà„®«“ ºª«¬°π¬“°ÕπÕ“À“√ — —‘ ‘ âŸ É â à âŸ É ‘ à ‚¥¬‡©æ“–¡◊ÈÕ‡¬Áπ µâÕ߉¡à „™à°àÕππÕπ 13.2 Õ“®æ®“√≥“‡æ¡¬“ H2RA (ranitidine 150 mg À√◊Õ cimetidine ‘ Ë‘ 400 mg) °àÕππÕπ „π°√≥’∑’Ë ß —¬«à“ºŸâªÉ«¬®–¡’¿“«– noctur- nal acid breakthrough 13.3 æ‘®“√≥“‡ª≈’ˬπ™π‘¥¢Õ߬“ PPI14. °“√µ√«®¥â«¬«‘∏’ ambulatory pH monitoring „π∑’Ë∑’Ë “¡“√∂∑”‰¥â Õ“®æ‘®“√≥“∑”µ—Èß·µà‡¡◊ËÕº≈°“√ àÕß°≈âÕßæ∫«à“ª°µ‘ ·≈–‰¡à¡’¢âÕ¡Ÿ≈ ‡æ‘Ë¡‡µ‘¡À≈—ß®“°°“√ª√–‡¡‘πºŸâªÉ«¬´È”„À¡à  ”À√—∫ºŸâªÉ«¬∑’Ë„Àâ°“√√—°…“ ¥â«¬ LSM ·≈–∑∫∑«π°“√„À⬓µ“¡¢âÕ 13 ·≈â« Õ“°“√‰¡à¥’¢÷È𠧫√ 殓√≥“ ßºª«¬µÕ‰ª¬ß ∂“∫π∑ “¡“√∂∑” ambulatory pH moni- ‘ à âŸ É à — — Ë’ toring ‰¥â15. Mild to moderate esophagitis ∂◊Õµ“¡°“√·∫à߇°√¥ ∂â“‚¥¬«‘∏’ Savary-Miller §◊Õ grade 1-3 À√◊Õ grade A ·≈– B ¢Õß Los Ange- les classification16.  ”À√—∫ Severe esophagitis ∂â“·∫àßµ“¡ Savary-Miller classifica- tion ®–‡∑à“°—∫ grade 4-5 À√◊Õ grade C ·≈– D ¢Õß Los Angeles classification. „π°√≥’∑’Ë ß —¬ Barrettûs esophagus ®“°°“√∑” endoscopic ex- 11
  12. 12. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ amination §«√∑”°“√µ—¥™‘Èπ‡π◊ÈÕ‡æ◊ËÕ àßµ√«® histology ∑ÿ°√“¬17. À≈—°°“√√—°…“‡À¡◊Õπ„π¢âÕ 13 [LSM/Intensify treatment (1)] ·µà ∂⓺ŸâªÉ«¬Õ“°“√¬—߉¡à¥’¢÷Èπ¢π“¥¢Õß H2RA Õ“®‡æ‘Ë¡‡ªìπ 2 ‡∑à“‰¥â ‡™àπ „Àâ ranitidine ‡ªìπ 300 mg ·∑π „π°√≥’∑’˺ŸâªÉ«¬‡ªìπ mild À√◊Õ moderate disease ¢Õß GERD À≈—ß°“√√—°…“®πºŸª«¬ Õ“°“√ ∫“¬¥’·≈⫺Ÿª«¬Õ“®°≈—∫¡“¡’Õ“°“√Õ’° â É â É °“√√—°…“À≈—ß®“°π’ÈÕ“®æ‘®“√≥“„À⬓‡ªìπ·∫∫ on-demand À√◊Õ in- termittent therapy À√◊ÕÕ“®®–µâÕßæ‘®“√≥“¬“„π¢π“¥πâÕ¬∑’ ¥∑’®– Ë ÿ Ë  “¡“√∂§«∫§ÿ¡Õ“°“√ºŸâªÉ«¬‰¥â (long term maintenance therapy) µ“¡«‘∏’ step down strategy „π°√≥’∑’˺ŸâªÉ«¬‡ªìπ severe esophagitis ºŸâªÉ«¬¡’ ‚Õ°“ ∑’Ë®–‡°‘¥ °“√°≈—∫‡ªìπ´È”‰¥â Ÿß‡¡◊ËÕÀ¬ÿ¥°“√√—°…“ ¥—ßπ—Èπ¡’·π«‚πâ¡∑’˵âÕß„™â¬“ ‡æ◊ËÕ§«∫§ÿ¡Õ“°“√‡ªìπ√–¬–‡«≈“π“π (long term maintenance therapy) ¥—߉¥â°≈à“«·≈â« ºŸâªÉ«¬∫“ß√“¬Õ“®µâÕß°‘𬓄π¢π“¥πâÕ¬  ÿ¥∑’Ë “¡“√∂§«∫§ÿ¡Õ“°“√‰¥â‡ªìπ√–¬–‡«≈“À≈“¬‡¥◊Õπ®π∂÷ßÀ≈“¬ªï  ”À√—∫°≈ÿà¡∑’ˇªìπ Barrettûs esophagus ¡’·π«‚πâ¡∑’˵âÕß„™â¬“ PPI ‡ªìπ√–¬–‡«≈“π“π √à«¡°—∫°“√∑” endoscopy surveillance ‡ªìπ √–¬–‡«≈“Àà“ß°—π 1-3 ªï (‚¥¬æ®“√≥“µ“¡·π«∑“ߢÕß American College of Gastroenterology) ‘ ¢âÕ∫àß™’È „π°“√æ‘®“√≥“„Àâ°“√√—°…“¥â«¬°“√ºà“µ—¥ ¡’¥—ßπ’È 1. ºŸâªÉ«¬∑’Ë°“√√—°…“¥â«¬¬“‰¥âº≈¥’ ·µà ‰¡àµâÕß°“√°‘𬓵àÕ‰ªÕ’°·≈– µâÕß°“√ºà“µ—¥ 2. ºŸâªÉ«¬∑’Ë ‰¡à “¡“√∂∑πµàÕ°“√„À⬓À√◊Õ¡’º≈¢â“߇§’¬ß®“°¬“À√◊Õ ‰¡à “¡“√∂°‘𬓉¥âÕ¬à“ß ¡Ë”‡ ¡Õ‡ªìπ√–¬–‡«≈“π“πÊ 3. ºŸª«¬∑’¡ª≠À“¥â“π‡»√…∞“π– â É Ë ’ í 4. ºŸª«¬Õ“¬ÿπÕ¬ â É â12
  13. 13. Guideline for the management of GERD °“√√—°…“¥â«¬«‘∏’Õ◊ËπÊ ‡™àπ °“√√—°…“¥â«¬°“√„™â‡§√◊ËÕß¡◊Õ Õÿª°√≥å 摇»… À√◊Õ °“√©’¥ “√‡§¡’ ‚¥¬°“√„™â°≈âÕß àÕß∑“߇¥‘πÕ“À“√ §«√ °√–∑”„π ∂“∫—π∑’Ë¡’§«“¡ “¡“√∂°√–∑”‰¥â ·≈–µâÕßæ‘®“√≥“‡ªìπ °√≥’摇»…‡ªìπ‡©æ“–√“¬‡∑à“π—ÈπÀ¡“¬‡Àµÿ: ™¡√¡‚¡∏‘≈‘µ’È·Ààߪ√–‡∑»‰∑¬ ¿“¬„µâ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ ‰¥â®—¥∑” Statement ‡√◊ËÕß·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕ¬„πª√–‡∑»‰∑¬ ´÷Ëß®–¡’√“¬≈–‡Õ’¬¥√«¡∑—ß¡’‡Õ° “√Õâ“ßՑ߇æ◊Õ„™âª√–°Õ∫°—∫ guideline „πÀπ—ß ◊Õ‡≈à¡π’È ·≈–‰¥â ßµàÕ È Ë à‰ª¬—ß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬, °√–∑√«ß “∏“√≥ ÿ¢·≈– ∂“∫—πæ—≤π“·≈–√—∫√Õߧÿ≥¿“æ‚√ß欓∫“≈ (æ√æ) ‡æ◊ËÕ‡º¬·æ√àµàÕ‰ª∑à“π “¡“√∂À“√“¬≈–‡Õ’¬¥‰¥â „π®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬,  “√√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ·≈–www.thaigastro.org 13
  14. 14. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕπ„π∑“√°·≈–‡¥Á° Infantile GER §◊Õ ¿“«– GER ∑’ˇ°‘¥¢÷Èπ„π∑“√°®–‡√‘Ë¡¡’Õ“°“√µß·µÕ“¬ÿ 1-3 ‡¥Õπ ‚¥¬®–¡“¥«¬Õ“°“√¢¬Õπ (regurgitation) ·≈–Õ“‡®¬π —È à ◊ â â ’(vomiting)  à«π„À≠à‡ªìπ uncomplicated GER ·≈–¡—°®–À“¬‡Õ߉¥â‡¡◊Õ ËÕ“¬ÿ 12-18 ‡¥◊Õπ ·µà¡’ºŸâªÉ«¬∫“ß√“¬∑’ËÕ“®‡°‘¥ GERD ‰¥â Adult type GER §◊Õ ¿“«– GERD ∑’ˇ°‘¥¢÷Èπ„π‡¥Á°‚µ‚¥¬¡’Õ“°“√‡√‘Ë¡µâπ‡¡◊ËÕÕ“¬ÿ¡“°°«à“ 1 ªï ¡—°®–‡ªìπ Ê À“¬ Ê·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“‚√§°√¥‰À≈¬âÕπ·∫à߇ªìπ°≈ÿࡵ“¡Õ“°“√À√◊Õ¿“«–·∑√°´âÕπ¥—ßπ’È 1. ∑“√°∑’Ë¡’Õ“°“√¢¬âÕπ (regurgitation)·≈–/À√◊ÕÕ“‡®’¬π 2. ∑“√°·≈–‡¥Á ° ∑’Ë ¡’ Õ “°“√¢¬â Õ π(regurgitation)·≈–/À√◊ Õ Õ“‡®’¬π√à«¡°—∫Õ“°“√¢ÕßGERD 3. GERD related respiratory diseases ‰¥â·°à apparent life- threatening event-ALTE , persistent asthma, recurrent pneumonia ·≈–§«“¡º‘¥ª°µ‘∑“߇¥‘πÀ“¬„®µÕπ∫π 4. GERD „π‡¥Á°∑’Ë¡’ªí≠À“∑“ß ¡ÕßÀ¡“¬‡Àµÿ: ‡¥Á°‚µ∑’Ë¡’ heartburn „™â·π«∑“ß°“√√—°…“ GERD „πºŸâ „À≠à14
  15. 15. Guideline for the management of GERD·ºπ¿Ÿ¡‘ 1 : ·π«∑“ß°“√ª√–‡¡‘π·≈–√—°…“∑“√°∑’¡Õ“°“√¢¬âÕπ (regurgi- Ë ’ tation) ·≈–/À√◊ÕÕ“‡®’¬π 1 Infant with regurgitation and vomiting 3 yes 2 Alarming symptoms of other diseases Investigate for other diagnosis 4 No Complications of GER No yes 5 GER GERD 8 6 ë Reassure wks ë LSM 2-4 7 Improve No improvement 8Resolve by 18months of age Consider Observe for GERD 8 hypoallergenic formula Physiologic GER 15
  16. 16. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ §”Õ∏‘∫“¬·ºπ¿Ÿ¡‘ 11. ¿“«–°√¥‰À≈¬âÕπ (gastroesophageal reflux-GER) æ∫‰¥â∫Õ¬„π∑“√° à ´÷Ëß à«π„À≠à ‰¡à°àÕ„À⇰‘¥‚√§À√◊Õ¿“«–·∑√°´âÕπ ·≈–¡—°®–‰¡àµâÕß°“√ √—°…“ ¿“«–°√¥‰À≈¬âÕπ∑’‡°‘¥¿“«–·∑√°´âÕπ ‡√’¬°«à“ ‚√§°√¥‰À≈¬âÕπ Ë (gastroesophageal reflux disease-GERD)2. Õ“°“√‡µ◊Õπ (alarming symptoms) ∑’Ë ”§—≠„π∑“√°∑’ËÕ“‡®’¬π´÷Ëß∫àß™’È «à“ “‡ÀµÿÕ“®¡‘„™à GER Õ“®¡’ “‡Àµÿ®“°‚√§Õ◊Ëπ ‰¥â·°à Õ“‡®’¬π¡’πÈ”¥’ ªπ Õ“‡®’¬πæÿàß Õ“‡®’¬π√ÿπ·√ß Õ“‡®’¬π‡√‘Ë¡µâπÕ“¬ÿ‡°‘π 6 ‡¥◊Õπ ‡≈◊Õ¥ ÕÕ°„π∑“߇¥‘πÕ“À“√ °¥‡®Á∫∑’ËÀπâ“∑âÕß ∑âÕßÕ◊¥ §≈”‰¥â°âÕπ∑’Ë∑âÕß ‰¢â µ—∫¡â“¡‚µ °√–À¡àÕ¡‚ªÉßµ÷ß »’√…–‡≈Á°À√◊Õ‚µº‘¥ª°µ‘ ™—° µ√«®æ∫ §«“¡º‘¥ª°µ‘√–∫∫ª√– “∑3. ¡’ alarming symptoms „Àâµ√«®§âπ‡æ‘Ë¡‡µ‘¡‡æ◊ËÕ«‘π‘®©—¬·¬°‚√§Õ◊Ëπ ÕÕ°‰ª‚¥¬¡’·π«∑“ßµ“¡µ“√“ß∑’Ë 14. ‰¡à¡’ alarming symptoms „Àâª√–‡¡‘π«à“¡’¿“«–·∑√°´âÕπ¢Õß GER À√◊Õ‰¡à (µ“√“ß∑’Ë 2)5 ∑“√°∑’Ë¡’Õ“°“√¢¬âÕπÀ√◊ÕÕ“‡®’¬π‚¥¬‰¡à¡’¿“«–·∑√°´âÕπ·≈–‰¡à ¡’ Õ“°“√·≈–Õ“°“√· ¥ß∑’∫ß™’∂ß‚√§Õ◊πÊ  “¡“√∂„Àâ°“√«‘π®©—¬ GER ‚¥¬ Ë à È÷ Ë ‘ ‰¡à®”‡ªìπµâÕß àßµ√«®«‘π‘®©—¬‡æ‘Ë¡‡µ‘¡ °“√√—°…“§◊Õ °“√ reassurance æàÕ·¡à √à«¡°—∫ life-style modification (LSM)6. Life-style modification (LSM) ‰¥â·°à 6.1 Feeding technique „ÀâÕ“À“√ª√‘¡“≥πâլʵàÕ¡◊ÈÕ ·µà „Àâ ®”π«π§√—Èß∫àÕ¬¢÷Èπ 6.2 Thickening formula ‚¥¬„™âπ¡ ”‡√Á®√Ÿª∑’˺ ¡ “√‡æ‘Ë¡ §«“¡Àπ◊¥ À√◊Õ‡µ√’¬¡‡Õß ‡™àπ º ¡ rice cereal ∑”„Àâ Õ“°“√·À«–π¡·≈–Õ“‡®’¬π„π∑“√°¥’¢÷Èπ 6.3 Hypoallergenic formula (‰¥â·°à extensively hydrolysed16
  17. 17. Guideline for the management of GERD formula) À√◊Õ soy formula „™â „π°√≥’∑’Ë ß —¬ cowûs milk protein allergy ´÷ËßÕ“®¡“¥â«¬Õ“°“√¢¬âÕπÀ√◊ÕÕ“‡®’¬π 6.4 Positioning °“√πÕπ§«Ë”®–™à«¬≈¥°“√‡°‘¥ GER ·µà§«√ √–¡— ¥ √–«— ß ‡π◊Ë Õ ß®“°„πµà “ ߪ√–‡∑»æ∫«à “ °“√πÕπ§«Ë” ¡’ ‚Õ°“ ‡°‘¥ sudden infant death syndrome Õ“®„ÀâπÕπ ∑“µ–·§ß´“¬·∑π °“√®∫∑“√°Õ¬Ÿà„π∑“µßµ√ß (upright) À≈ß à â — à —È — °‘ππ¡‡ªìπ‡«≈“ª√–¡“≥ 15-20 π“∑’·≈–À≈’°‡≈’ˬ߰“√°¥ ∫√‘‡«≥∑âÕß®–™à«¬≈¥Õ“°“√Õ“‡®’¬π7. À“°Õ“°“√¥’¢÷È𠧫√µ‘¥µ“¡ºŸâªÉ«¬‡ªìπ√–¬–Ê ®π°«à“Õ“°“√®–À“¬‰ª ‡¥Á°∑’ËÕ“°“√À“¬¿“¬„πÕ“¬ÿ 18 ‡¥◊Õπ ‚¥¬‰¡à¡’¿“«–·∑√°´âÕπ∂◊Õ«à“ ‡ªìπ physiologic GER8. „π√“¬∑’Ë ‰¡à¥¢π §«√µ‘¥µ“¡¥Ÿ„°≈♥«à“¡’¿“«–·∑√°´âÕπ (GERD) À√◊Õ ’ ÷È ‘ ‰¡à ‡¥Á°°≈ÿ¡π’ «πÀπ÷ßÕ“®‡ªìπ cowûs milk protein allergy æ‘®“√≥“ à È à Ë ≈Õß„Àâ hypoallergenic formula 1-2  —ª¥“Àå·≈–¥Ÿ°“√µÕ∫ πÕß À“° ¥’¢÷Èπ™—¥‡®π πà“®–‡ªìπ cowûs milk protein allergy ∂⓺ŸâªÉ«¬¡’¿“«– ·∑√°´Õπ¢Õß GER À√Õ„À°“√√°…“‚¥¬ LSM À√Õ‰¥√∫ hypoallergenic â ◊ â — ◊ â— formula ·≈⫉¡à¥’¢÷Èπ„À⥟·ºπ¿Ÿ¡‘∑’Ë 2 17
  18. 18. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬·ºπ¿Ÿ¡‘ 2: ·π«∑“ß°“√ª√–‡¡‘π·≈–√—°…“∑“√°·≈–‡¥Á°∑’Ë¡’Õ“°“√¢¬âÕπ (regurgitation)·≈–/À√◊Õ Õ“‡®’¬π√à«¡°—∫Õ“°“√¢Õß GERD 1 Regurgitation/ vomiting with GERD symptoms 2 3 4 Suspected Suspected Poor weight gain of CMPA of esophagitis despite of proper feeding Trial ofhypoallergenic ë LSM formula ë GI contrast study ë Acid suppression + ë Screening labs prokinetic Rx 2-4 wks Normal Abnormal 5 LSM 1-2 wks Improve Continue Rx until resolved Symptom persist Prokinetic and/or acid suppression Rx 2-4 wks 6 Response No response Continue Rx 8-12 Consult Ped GI wks or until 9-12 Upper endoscopy months of age GERD Other diagnosis Optimized medical Rx Rx accordingly18
  19. 19. Guideline for the management of GERD §”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 21. ∑“√°·≈–‡¥Á ° ∑’Ë ¡’ ¢ ¬â Õ πÀ√◊ Õ Õ“‡®’ ¬ π·≈–¡’ Õ “°“√∫à ß ™’È ∂÷ ß ¿“«– ·∑√°´âÕπ¢Õß GER (µ“√“ß∑’Ë 2)2. ‡¥Á°∑’‡ªìπ cowûs milk protein allergy Õ“®¡“¥â«¬Õ“°“√·∫∫ GERD Ë À“° ß —¬¿“«–π’ȧ«√≈Õß„Àâ hypoallergenic formula (‰¥â·°à exten- sively hydrolysed formula) À√◊Õ soy formula 1-2  —ª¥“Àå·≈–¥Ÿ °“√µÕ∫ πÕß3. À“°ºŸâªÉ«¬¡’Õ“°“√ ß —¬ esophagitis ‡™àπ ∑“√°∑’Ë√âÕß°«πº‘¥ª°µ‘ ªØ‘‡ ∏°“√°‘πÕ“À“√ À≈—ß·Õàπ‡°√Áß (back arching) ´’¥ ‡¥Á°‚µÕ“®¡’ heartburn ‡ªìπµâπ °“√√—°…“§◊Õ „À⬓ acid suppression (µ“√“ß∑’Ë 3) ‡ªìπÀ≈—° Õ“®æ‘®“√≥“„Àâ prokinetic drug √à«¡¥â«¬ °“√„À⬓„Àâ ∑”§«∫§Ÿà ‰ª°—∫ LSM4. ºŸâªÉ«¬∑“√°·≈–‡¥Á°∑’Ë¡’Õ“°“√Õ“‡®’¬π√à«¡°—∫πÈ”Àπ—°¢÷Èπ™â“ „π¢≥–∑’Ë Õ“À“√∑’Ë „Àâ¡’ª√‘¡“≥‡æ’¬ßæÕ·≈–‰¡à¡’§«“¡º‘¥ª°µ‘∑’Ë∫àß™’È∂÷ß‚√§√–∫∫ Õ◊πÊ (µ“√“ß∑’Ë 1) ºŸª«¬§«√‰¥â√∫°“√µ√«®∑“ß√—ß ’«∑¬“‚¥¬°“√∑” GI Ë â É — ‘ contrast study ‡æ◊ËÕ·¬°¿“«–∑“߇¥‘πÕ“°“√Õÿ¥°—ÈπÕÕ°‰ª „π∑“√° §«√ à߇≈◊Õ¥µ√«®∑“ßÀâÕߪؑ∫—µ‘°“√‡∫◊ÈÕßµâπ‡æ◊ËÕ·¬° “‡ÀµÿÕ◊ËπÊ‚¥¬ ‡©æ“–∑“߇¡µ“∫Õ≈‘§ ‡™àπ CBC, electrolytes, blood sugar, BUN, Cr, ammonia, urinalysis ‡ªìπµâπ5. À“°º≈°“√µ√«® GI contrast study ·≈–°“√µ√«®∑“ßÀâÕߪؑ∫—µ‘ °“√‡∫◊Õßµâπ¥—ß°≈à“«¢â“ßµâπ‰¡àæ∫§«“¡º‘¥ª°µ‘„¥Ê „Àâ°“√√—°…“‚¥¬ life È style modification (LSM) ¥—ß°≈à“«„π§”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 1 À“° ‡ªìπ‡¥Á°‚µ„ÀâªØ‘∫µ¥ßπ’È —‘— o πÕπµ–·§ß´â“¬·≈–À—« Ÿß o §«√À≈°‡≈¬ßÕ“À“√‡º¥À√Õ√ ®¥ Õ“À“√¡π πȔե≈¡ ™Õ°‚°·≈µ ’ ’Ë Á ◊ — — — Á °“·ø ·Õ≈°ÕŒÕ≈å 19
  20. 20. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ o §«√§«∫§ÿ¡πÈ”Àπ—°‰¡à„ÀâÕâ«π‡°‘π‰ª o ‰¡à§«√°‘πÕ“À“√°àÕππÕπ o ‰¡à§«√°‘πÕ“À“√ª√‘¡“≥¡“°‡°‘π‰ª„π·µà≈–¡◊ÈÕ À“°ºŸâªÉ«¬‰¡à¥’¢÷Èπ„π√–¬–‡«≈“ 1-2  —ª¥“Àå §«√√—°…“¥â«¬¬“‚¥¬ „À⬓ prokinetic (µ“√“ß∑’Ë 3) Õ“®æ‘®“√≥“„À⬓°≈ÿà¡ acid suppres- sion (µ“√“ß∑’Ë 3) √«¡¥«¬ §«√„À°“√√°…“¥«¬¬“‡ªπ‡«≈“ 2-4  ª¥“Àå à â â — â ì — ·≈⫪√–‡¡‘π°“√µÕ∫ πÕß „πºŸâªÉ«¬∑’Ë¡’Õ“°“√√ÿπ·√ßÕ“®æ‘®“√≥“ √—°…“¥â«¬¬“‰ªæ√âÕ¡Ê °—∫ LSM ‰¡à®”‡ªìπµâÕß√ÕÕ’° 1-2  —ª¥“Àå6. ‡¡◊ËÕ√—°…“¥â«¬¬“‡ªìπ‡«≈“ 2-4  —ª¥“Àå ¬—߉¡à ‰¥âº≈§«√ àßµàÕ°ÿ¡“√ ·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√ª√–‡¡‘πºŸâªÉ«¬µàÕ‰ª ´÷Ëß®”‡ªìπµâÕß∑” up- per endoscopy ·≈– biopsy ‡æ◊ËÕ∑”°“√«‘π‘®©—¬‚√§Õ◊ËπÊ ∑’Ë¡’ Õ“°“√§≈⓬°—∫ GERD ‡™àπ esoinophilic esophagitis, cow milk protein allergy, peptic ulcer disease ‡ªìπµâπ √«¡∑—Èßæ‘®“√≥“ °“√µ√«®Õ◊ËπÊ ‡™àπ 24- h esophageal pH monitoring ‡ªìπµâπ À“° º≈°“√µ√«®æ∫«à“¡’ GERD §«√√—°…“‚¥¬°“√„À⬓∑’Ë¡’ª√– ‘∑∏‘¿“楒 ¢÷Èπ·≈–æ‘®“√≥“„Àâ¢π“¥¬“ Ÿß¢÷Èπ (µ“√“ß∑’Ë 3)20
  21. 21. Guideline for the management of GERD·ºπ¿¡‘ 3 : ·π«∑“ß°“√ª√–‡¡π·≈–√°…“∑“√°·≈–‡¥°∑ ß ¬ GERD Ÿ ‘ — Á Ë’ — related respiratory diseases Patient suspected of GERD related respiratory diseases after excluding other causes Esophageal symptoms of GERD 1 Yes ë LSM No ë Acid suppression + 2 prokinetic 2-4 wks ë Barium swallow (swallowing as- sessment) or UGIS Clinical No ë Consult Pediatric pulmonologist Improvement ? ë Consult Pediatric GI Yes ë Esophageal pH monitoring ë Consider other investigations eg. Continue Rx for scintigraphy, lipid laden mac- 3-6 months rophage, etc Relapse after Yes stop No Observation §”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 31. ∂â“¡’Õ“°“√ typical GERD ‰¥â·°à ¢¬âÕπ Õ“‡®’¬π heartburn √à«¡¥â«¬ „Àâ≈Õß√—°…“·∫∫ GERD ‰ª°àÕπ ∂⓵Õ∫ πÕߥ’„Àâ√—°…“µàÕπ“π 3-6 ‡¥◊Õπ ∂Ⓣ¡àµÕ∫ πÕßÀ√◊Õ°≈—∫¡“‡ªìπ„À¡àÀ≈—ßÀ¬ÿ¥°“√√—°…“ „À⠪ؑ∫µµ“¡¢âÕ 2 —‘ 2. ∂Ⓣ¡à¡Õ“°“√ typical GERD §«√ ßµ√«®‡æ¡‡µ¡‡æÕ«π®©¬ GERD ’ à ‘Ë ‘ ◊Ë ‘ ‘ — ´÷Ëߢ÷Èπ°—∫§«“¡ “¡“√∂¢Õß·µà≈–‚√ß欓∫“≈ 21
  22. 22. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬·ºπ¿Ÿ¡‘∑’Ë 4: ·π«∑“ß°“√ª√–‡¡‘π·≈–√—°…“ GERD „π‡¥Á°∑’Ë¡’ªí≠À“∑“ß  ¡Õß∑’Ë „ à PEG À√◊Õ„ à nasogastric tube ·≈–/À√◊Õ «“ß·ºπ∑” PEG 1 Neurologically impaired children with feeding difficulty 4 2 Atypical ë GI contrast study Occupation ë Other investigations Vomiting therapist symptoms of GERD ë Slowly drip in 1-2 hr/feeding LSM + acid suppression ë LSM Rx + prokinetic 2-4 wks Yes Response Continue Rx Response? No Trial of prokinetic and/or acid No suppression Rx 2-4 wk Yes ë Consult Ped GI Continue Rx ë Investigations eg. for 3-6 mo pH monitoring, upper Response endoscopy, etc Recurrent symptoms Yes No 3 Continue Rx ë Consult Ped GI No 5 GERD ë Upper endoscopy Further investigations No Erosive Acid suppression Rx and esophagitis esophagitis prokinetic 6-8 wks No response Fundoplication22
  23. 23. Guideline for the management of GERD §”Õ∏‘∫“¬·ºπ¿Ÿ¡‘∑’Ë 41. ‡¥Á°∑’Ë°≈◊πÕ“À“√‡Õ߉¡à ‰¥â §«√‰¥â√—∫°“√∑” gastrostomy „π√æ.∑’Ë  “¡“√∂∑” percutaneous endoscopic gastrostomy (PEG) ‰¥â „Àâ‡≈◊Õ°∑” PEG ‡ªìπÕ—π¥—∫·√°°àÕπ ·µà„πºŸª«¬∑’«“ß·ºπ®–∑” sur- â É Ë gical gastrostomy Õ¬Ÿà·≈â«À“°¡’Õ“°“√ ß —¬ GERD ·≈–‰¥â√—∫ °“√µ√«®¬◊π¬—π«‘π‘®©—¬«à“¡’ GERD §«√∑” surgical gastrostomy ·≈– fundoplication ‰ªæ√âÕ¡°—π2. ∂â“¡’Õ“°“√Õ“‡®’¬π „Àâµ√«®À“ “‡ÀµÿÕ◊ËπÊ·≈–„Àâ°“√√—°…“µ“¡ “‡Àµÿ ∂“µ√«®·≈«ª°µ„À≈Õß„ÀÕ“À“√∑“ß “¬Õ¬“ß™“ Ê √«¡°∫ LSM ∂“ â â ‘ â â à â à — â ‰¡à¥’¢÷Èπ„Àâ°“√√—°…“¥â«¬¬“√—°…“ GERD3. ‡¡◊Õ√—°…“·≈⫉¡à‰¥âº≈ µâÕß∑” upper endoscopy ∂â“æ∫«à“‰¡à¡’ esoph- Ë agitis „Àâ∑”ºà“µ—¥ fundoplication ·µà∂â“æ∫«à“¡’ erosive esophagitis „Àâ≈Õß√—°…“¥â«¬¬“ acid suppression „À⇵Á¡∑’ËÕ’°§√—Èß√à«¡°—∫ prokinetic À“°√—°…“¥â«¬¬“‰¡à¥’¢÷È𠧫√∑”ºà“µ—¥ fundoplication æ‘®“√≥“∑”√à«¡°—∫ surgical gastrostomy („π√“¬∑’ˬ—ß¡‘‰¥â∑” PEG)4. ºŸâªÉ«¬¡’Õ“°“√ atypical GERD Õ“®≈Õß„Àâ°“√√—°…“ GERD ‰ª‡≈¬ À√◊Õ àßµàÕ‡æ◊ËÕ∑”°“√µ√«®«‘π‘®©—¬ GERD À“°√—°…“¥â«¬¬“·≈â«¥’¢÷Èπ „Àâ√°…“µàÕπ“π 3-6 ‡¥◊Õπ ∂Ⓣ¡à¥¢π§«√ àßµàÕ‡æ◊Õµ√«®«‘π®©—¬ GERD — ’ ÷È Ë ‘5. ‡¡◊ËÕ°“√µ√«®«‘π‘®©—¬¬◊π¬—π GERD Õ“®≈Õß„Àâ°“√√—°…“¥â«¬¬“ 6-8  —ª¥“ÀåÀ√◊ÕÕ“®∑”°“√ºà“µ—¥ fundoplication ‰ª‡≈¬ À“°√—°…“¥â«¬ ¬“‰¡à¥’¢÷Èπ§«√∑”ºà“µ—¥ fundoplication æ‘®“√≥“∑”√à«¡°—∫ surgical gastrostomy („π√“¬∑’ˬ—ß¡‘‰¥â∑” PEG) 23
  24. 24. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬µ“√“ß∑’Ë 1. Õ“°“√·≈–Õ“°“√· ¥ß·≈–°“√«‘π‘®©—¬·¬°‚√§„π∑“√°·≈– ‡¥Á°∑’¡“¥â«¬Õ“‡®’¬π Ë°≈ÿà¡‚√§ Õ“°“√·≈–Õ“°“√· ¥ß∑’Ë ”§—≠ ‚√§ InvestigationGI - Projectile vomiting with Pyloric stenosis Abdominal US, UGISobstruction epigastric mass, FTT - Bilious vomiting, abdominal Small bowel obstruction, UGIS/LGIS distention, mass malrotation with intermittent volvulus - Abdominal distention/ Hirschsprungûs disease Barium enema constipation GI disorders - Hematemesis/hematochezia, Gastritis/duodenitis Upper endoscopy abdominal pain - Hematemesis/hematochezia, CMPA, food allergy Food challenge edema, anemia, skin rash, FTT - Hematemesis, dysphagia, Eosinophilic esophagitis Upper endosopy feeding refusal - Abdominal distension, Gastroparesis Gastric emptying study early satiety - Dysphagia Achalasia Barium swallowing Neurologic - Bulging anterior fontanelle, Hydrocephalus Neuroimaging study conditions macrocephaly, seizure, Intracranial mass weakness, signs of increased ICP Infection - Fever, lethargy Meningitis/sepsis Septic work up - Dysuria Urinary tract infection Urine exam and culture Metabolic - Lethargy, hepatomegaly Urea cycle defect Metabolic work up and - Abnormal genitalia, CAH endocrine hyperpigmentation disorders - Hepatosplenomegaly, jaundice, Galactosemia cataract - Septic-like episode, metabolic Organic acidemia acidosis Toxic History of exposure or ingestion Lead, iron, vitamin A or D Toxicology work up substancesFTT=failure to thrive, CMPA=cowûs milk protein allergy, US=ultrasonography, UGIS=upperGI study, LGIS=Long GI study, ICP=intracranial pressure, CAH=congenital adrenal hyper-plasia24
  25. 25. Guideline for the management of GERDµ“√“ß∑’Ë 2 ¿“«–·∑√°´âÕπ¢Õß GER (GERD) 1. √–∫∫∑“߇¥‘πÕ“À“√ Õ“‡®’¬π‡ªìπ‡≈◊Õ¥ ´’¥ À≈Õ¥Õ“À“√Õ—°‡ ∫ persistent irritability À≈Õ¥Õ“À“√µ’∫ (stricture) ªØ‘‡ ∏Õ“À“√ Barrettûs esophagus °≈◊π≈”∫“° °≈◊π·≈⫇®Á∫ heartburn ª«¥∑âÕß∫√‘‡«≥≈‘Èπªïò 2. √–∫∫∑“߇¥‘πÀ“¬„® Asthma À√Õ recurrent wheezing Recurrent pneumonia / bronchitis ◊ Stridor Hoarseness Apnea À√◊Õ apparent life-threatening event (ALTE) 3. √–∫∫Õ◊πÊ Ë πÈ”Àπ—°¢÷Èπ™â“ ‡≈’Ȭ߉¡à ‚µ Abnormal posture (Sandifer syndrome) 25
  26. 26. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬µ“√“ß∑’Ë 3 ¬“∑’Ë„™â „π°“√√—°…“ GERD „π‡¥Á° ™π‘¥¢Õ߬“ ¢π“¥¬“ ¢π“¥¬“ Ÿß ÿ¥ ë Prokinetics - Metoclopramide 0.1 ¡°./°°./§√—Èß 5 ¡°. «—π≈– 3-4 §√—Èß «—π≈– 3-4 §√—Èß - Domperidone 0.3-0.6 ¡°./°°./§√—Èß 10 ¡°. «—π≈– 3-4 §√—Èß «—π≈– 3-4 §√—Èß - Cisapride* 0.2 ¡°./°°./§√—Èß 10 ¡°. «—π≈– 3-4 §√—Èß «—π≈– 3-4§√—Èß ë H2 receptor antagonists (H2RA) - Cimetidine 40 ¡°./°°./«—π 800-1200 ¡°. ·∫àß«—π≈– 3 §√—Èß «—π≈– 2-3 §√—Èß - Ranitidine 5-10 ¡°./°°./«—π ·∫àß«—π≈– 2 À√◊Õ 3 §√—Èß 300 ¡°. «—π≈– 2 §√—Èß - Famotidine 1 ¡°./°°./«—π 20 ¡°. «—π≈– 2 §√—Èß ·∫àß«—π≈– 2 §√—Èß ë Proton pump inhibitors - Omeprazole 1-2 ¡°./°°./«—π 40 ¡°. «—π≈– 1-2 §√—Èß „Àâ«—π≈– 1 À√◊Õ 2 §√—Èß Õ“®‡æ‘Ë¡‰¥â∂÷ß 3.5 ¡°./°°./«—π - Lansoprazole 0.7-1.4 ¡°./°°./«—π 30 ¡°. «—π≈– 1-2 §√—Èß „Àâ«—π≈– 1-2 §√—Èß À√◊Õ 15 ¡°.«—π≈– 1 §√—ß È (ππ< 30 °°.), 30 ¡°. «—π≈– 1 §√—Èß (ππ> 30 °°.)26
  27. 27. Guideline for the management of GERDÀ¡“¬‡Àµÿ* Àâ “ ¡„™â „πºŸâªÉ«¬∑’Ë¡’ QT prolong Àâ“¡„™â√à«¡°—∫¬“°≈ÿà¡macrolides, azole antifungus, protease inhibitor §«√À≈’°‡≈’ˬ߰“√„™â „π∑“√°‡°‘¥°àÕπ°”Àπ¥ §«√„™âÕ¬à“ß√–¡—¥√–«—ß„πºŸâªÉ«¬∑’Ë¡’ ‚√§À—«„®ºŸâªÉ«¬∑’Ë¡’§«“¡º‘¥ª°µ‘¢Õß “√Õ’‡≈Á§‚∑√‰≈∑å ºŸâªÉ«¬‚√§µ—∫·≈–‰µ 27
  28. 28. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ √“¬π“¡ºŸâ‡¢â“ª√–™ÿ¡ —¡¡π“ Consensus for Clinical Practice Guideline „πºŸâ„À≠à §√—Èß∑’Ë 1 «—π∑’Ë 14-15 ¡‘∂ÿπ“¬π 2546 ≥ ‚√ß·√¡ Anantara ®.‡æ™√∫ÿ√’ §√—Èß∑’Ë 2 «—π∑’Ë 24-25 ¡°√“§¡ 2547 ≥ ‚√ß·√¡ Kanary Bay ®.√–¬Õßπæ.‡°√’¬ß‰°√ Õ—§√«ß»å √æ. ¡‘µ‘‡«™ °√ÿ߇∑æœπæ.·®à¡»—°¥‘Ï ‰™¬§ÿ≥“ √æ.»‘√√“™ ‘ °√ÿ߇∑ææ≠.‚©¡»√’ ‚¶…‘µ™—¬«—≤πå √æ.√“¡“∏‘∫¥’ °√ÿ߇∑æœπæ.µ«ß‡°’¬√µ‘ ‡®’¬¡Õÿ¥¡æß…å √æ.ª√“®’π∫ÿ√’ ª√“®’π∫ÿ√’πæ.∂πÕ¡ ®‘« ◊∫æß…å √æ. «√√§åª√–™“√—°…å π§√ «√√§åπæ.∑Õߥ’ ™—¬æ“π‘™ √æ. ¡‘µ‘‡«™ °√ÿ߇∑æœπæ.∏π“ Õ—ß ÿ«√√—ß…’ √æ.»‘√‘√“™ °√ÿ߇∑æœπæ.∏‡π» ®¥«≤π°≈ — — ÿ √æ. ¡‡¥®æ√–∫√¡√“™‡∑«’ Á ≥ »√’√“™“ ™≈∫ÿ√’πæ.∏’√–æß…å  ÿ¢‰æ»“≈ √æ. ß¢≈“π§√‘π∑√å  ß¢≈“πæ.∫—≠™“ ‚Õ«“∑Ó√æ√ √æ. ß¢≈“π§√‘π∑√å  ß¢≈“æ≠.ª≥‘∏“π  —πµ‘¿«—ߧå √æ.π§√ «√√§å π§√ «√√§åπæ.æ‘π‘® °ÿ≈≈–«≥‘™¬å √æ.®ÿÓ≈ß°√≥å °√ÿ߇∑æœπæ.æ‘æ—≤πå ®‘√π—¬√“¥ÿ≈ √æ.æ–‡¬“ æ–‡¬“πæ.æŸπ∑√—æ¬å «ß»å ÿ√‡°’¬√µ‘ √æ.»‘√‘√“™ °√ÿ߇∑æœπæ.¿—∑√“¬ÿ  ÕÕª√–¬Ÿ√ √æ.æ√–ª°‡°≈â“ ®—π∑∫ÿ√’28
  29. 29. Guideline for the management of GERDπæ.¡°√‡∑æ ‡∑æ°“≠®π“ √æ.√—™¥“-∑à“æ√– °√ÿ߇∑æœπæ.¬»æ√ ‚ ¿≥∏π–»‘√‘ √æ.‚Õ‡«Õ√å∫§ äÿ ‡™’¬ß√“¬æ≠.√—µπ“ ∫ÿ≠»‘√‘®—π∑√å √æ.«™‘√欓∫“≈ °√ÿ߇∑æœπæ.√“«‘π ‚´π’Ë √æ.»Ÿπ¬å≈”ª“ß ≈”ª“ßæ≠.«—≤π“  ÿ¢’‰æ»“≈‡®√‘≠ √æ.»√’π§√‘π∑√å ¢Õπ·°àπæ∑.πæ.«“π‘™ ªî¬π‘√—π¥√å √æ.æ√–¡ß°ÿ؇°≈â“ °√ÿ߇∑æœπÕ.πæ.«‘≠êŸ ®—π∑√ ÿπ∑√°ÿ≈ √æ.¿Ÿ¡‘æ≈Õ¥ÿ≈‡¥™ °√ÿ߇∑æœπæ.«‘∑Ÿ√ ™‘π «à“ß«—≤π°ÿ≈ √æ.»‘√‘√“™ °√ÿ߇∑æœπæ.«ÿ≤‘™—¬  ÿ∑∏‘∂«‘≈ √æ.æ√–¡ß°ÿ؇°≈â“ °√ÿ߇∑æœπæ.»µ«√√… ∑Õß «— ¥‘Ï √æ.¡À“√“™π§√‡™’¬ß„À¡à ‡™’¬ß„À¡àæ≠.»‘√‘æ√ ™’‡®√‘≠ √æ.«‘™—¬¬ÿ∑∏ °√ÿ߇∑æœπæ.»ÿ¿™—¬ »√’»‘√‘√ÿàß √æ.æ≠“‰∑-»√’√“™“ ™≈∫ÿ√’πæ. ¡™“¬ ≈’≈“°ÿ»≈«ß»å √æ.»‘√‘√“™ °√ÿ߇∑æœæ≠. ”√“≠ °≈—Ëπ·æ∑¬å°‘® √æ.°≈“ß °√ÿ߇∑æœπæ. ‘π Õπÿ√“…Ø√å √æ.∫”√ÿß√“…Ø√å °√ÿ߇∑æœπæ. ÿ‡®µπå ‡≈‘»‡Õπ°«—≤π“ √æ.ÀπÕߧ“¬ ÀπÕߧ“¬πæ. ÿ‡∑æ °≈™“≠«‘∑¬å √æ.®ÿÓ≈ß°√≥å °√ÿ߇∑æœπæ. ÿæ®πå æß»åª√– ∫™—¬ √æ.»‘√‘√“™ °√ÿ߇∑æœæÕ.πæ. ÿ√æ≈  ÿ√“ߧå»√’√—∞ √æ.æ√–¡ß°ÿƇ°≈â“ °√ÿ߇∑æœπæ. ÿ√‘¬– ®—°°–æ“° √æ.√“¡“∏‘∫¥’ °√ÿ߇∑æœπæ.Õ”π“® ®‘µ√«√π—π∑å √æ.‡®√‘≠°√ÿߪ√–™“√—°…å °√ÿ߇∑æœπæ.Õÿ¥¡ §™‘π∑√ √æ.»‘√‘√“™ °√ÿ߇∑æœπæ.‚ÕÓ√ «‘«—≤π“™à“ß √æ.Õÿ¥√∏“π’ Õÿ¥√∏“π’ 29
  30. 30. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬ √“¬π“¡ºŸâ‡¢â“ª√–™ÿ¡ —¡¡π“ Consensus for Clinical Practice Guideline „π‡¥Á° «—π∑’Ë 14-15 ¡‘∂ÿπ“¬π 2546 ≥ ‚√ß·√¡ Anantara ®.‡æ™√∫ÿ√’æ≠.‡°»√“ Õ—»¥“¡ß§≈ §≥–·æ∑¬»“ µ√å ¡À“«∑¬“≈¬»√π§√π∑√«‚√≤ ‘ — ’ ‘ ‘ π§√𓬰πæ.≥∞æß…å Õ§√º≈ — — √æ.¡À“√“™π§√‡™¬ß„À¡à ’ ‡™¬ß„À¡à ’æ≠.π¿Õ√ ¿“«®µ√ ‘‘ √æ.æ√–¡ß°Æ‡°≈“ ÿ â °√߇∑æœ ÿæ≠.𑬖¥“ «‘∑¬“»—¬  ∂“∫—π ÿ¢¿“懥Á°·Ààß™“µ‘¡À“√“™‘π’ °√ÿ߇∑æœæ≠.∫…∫“ ««≤π‡«§π √æ.®Ã“≈ß°√≥å ÿ ‘— å ‘ ÿ °√߇∑æœ ÿπæ.ª√–æπ∏å Õ“π‡ª√Õß √æ.»√√“™ — à Ë◊ ‘‘ °√߇∑æœ ÿæ≠.ª“𬓠‡æ¬√«®µ√ √æ.√“¡“∏∫¥’ ’ ’ ‘‘ ‘ °√߇∑æœ ÿæ≠.‡æÁ≠»√’ ‚§« ÿ«√√≥ √æ.»√’π§√‘π∑√å ¢Õπ·°àπæ≠.‡æ¬ßæπ∏å ∫≠»√’ √æ.°√߇∑æ§√ ‡µ¬π ’ — ÿ ÿ ‘ ’ °√߇∑æœ ÿæ≠.«√πÿ™ ®ß»√’ «— ¥‘Ï √æ.®ÿÓ≈ß°√≥å °√ÿ߇∑æœæ≠.«π¥’ «√“«∑¬å — ‘ √æ.√“¡“∏∫¥’ ‘ °√߇∑æœ ÿπæ.«°√¡ °√√≥ °≈ ‘ ÿ √æ.»√√“™ ‘‘ °√߇∑æœ ÿπæ. ß«π»°¥Ï‘ ƒ°…»¿º≈ §≥–·æ∑¬»“ µ√å — åÿ ¡À“«∑¬“≈¬»√π§√π∑√«‚√≤ ‘ — ’ ‘ ‘ π§√𓬰æ≠. æ√ µ√æß…°√≥“ √æ.√“¡“∏∫¥’ ÿ ’ å ÿ ‘ °√߇∑æœ ÿ¥√. ¿®©√“ πæ®π¥“ √æ.√“¡“∏∫¥’ ÿ— ‘ ‘ °√߇∑æœ ÿπæ.‡ ° µ ‚Õ ∂“°≈ ‘ ÿ √æ. ß¢≈“π§√π∑√å ‘  ß¢≈“30
  31. 31. Guideline for the management of GERD §≥–°√√¡°“√¥”‡π‘πß“π™¡√¡‚¡∏‘≈‘µ’È·Ààߪ√–‡∑»‰∑¬  ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ «“√– æ.».2546-25471. 𓬷æ∑¬å ‘π Õπÿ√“…Ø√å ∑’˪√÷°…“2. 𓬷æ∑¬åæ‘π‘® °ÿ≈≈–«≥‘™¬å ∑’˪√÷°…“3. ·æ∑¬åÀ≠‘ß«—π¥’ «√“«‘∑¬å ∑’˪√÷°…“4. 𓬷æ∑¬åÕÿ¥¡ §™‘π∑√ ª√–∏“π°√√¡°“√5. æ—π‚∑𓬷æ∑¬å«“π‘™ ªî¬π‘√—π¥√å ‡À√—≠≠‘°6. 𓬷æ∑¬å°µµ‘ ®—π∑√å‡≈‘»ƒ∑∏‘Ï ‘ °√√¡°“√7. ·æ∑¬åÀ≠‘ß‚©¡»√’ ‚¶…‘µ™—¬«—≤πå °√√¡°“√8. 𓬷æ∑¬å«∑√ ™‘π «à“ß«—≤π°ÿ≈ ‘ Ÿ °√√¡°“√9. 𓬷æ∑¬å∫≠™“ ‚Õ«“∑Ó√æ√ — °√√¡°“√10. ·æ∑¬åÀ≠‘ß∫ÿ…∫“ «‘«≤π凫§‘π — °√√¡°“√11. 𓬷æ∑¬åª√–æ—π∏å Õà“π‡ª√◊Õß Ë °√√¡°“√12. ·æ∑¬åÀ≠‘ß«‚√™“ ¡À“™—¬ °√√¡°“√13. π“«“‡Õ°π“¬·æ∑¬å«‘≠êŸ ®—π∑√ ÿπ∑√°ÿ≈ °√√¡°“√14. 𓬷æ∑¬å»µ«√√… ∑Õß «— ¥‘Ï °√√¡°“√15. 𓬷æ∑¬å ÿ‡∑æ °≈™“≠«‘∑¬å °√√¡°“√16. 𓬷æ∑¬å‡ ° ‘µ ‚Õ ∂“°ÿ≈ °√√√¡°“√17. æ—π‡Õ°π“¬·æ∑¬å ÿ√æ≈  ÿ√“ߧå»√’√—∞ °√√¡°“√18. ·æ∑¬åÀ≠‘ß ÿæ√ µ√’æß…å°√ÿ≥“ °√√¡°“√19. 𓬷æ∑¬å ÿ√‘¬– ®—°°–æ“° °√√¡°“√20. 𓬷æ∑¬ ¡™“¬ ≈≈“°»≈«ß»å å ’ ÿ °√√¡°“√·≈–‡≈¢“π°“√ ÿ 31
  32. 32. ·π«∑“ß°“√«‘π‘®©—¬·≈–√—°…“ ‚ √ § ° √ ¥ ‰ À ≈ ¬â Õ π „πª√–‡∑»‰∑¬Note..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................32

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