ulcers and reflux disease (GERD)

Introduction

Irritation of the upper gastrointestinal (GI) tract, including the oesophagus, stomach and duodenum is a very common condition affecting over 25 million people in the US daily and up to 60 million Americans each month. There are 500,000 to 850,000 new cases each year in the US and over one million hospitalizations for these conditions each year. It affects persons of all ages. Medical evaluation and treatment cost Americans $2 billion in 1996 while indirect costs from lost wages and productivity were estimated at $500,000, 000. The range of symptoms spans from occasional irritation after eating a spicy meal to catastrophic bleeding and death from ulceration. Because of the spectrum of disease, airman/controllers using medication for these conditions may be required to demonstrate freedom from ulcers to maintain their medical certification. Most medications used to treat these diseases may be waived for use during aviation duties once the condition is controlled.

GERD

Gastrooesophageal reflux disease (GERD) involves stomach contents and acid moving back into the oesophagus, the tube between the mouth and stomach. Ulcers of the oesophagus do not usually form, but chronic reflux may cause other problems. The consequences include scarring of the lower oesophagus and the formation of strictures with impair swallowing. The lining of the oesophagus changes when repeatedly exposed to acid. This change may lead to a condition known as Barrett’s oesophagus, which may lead to the cancer of the oesophagus. GERD can often cause asthma or allergy symptoms with coughing, especially in young children. GERD is usually caused by a weakness or relaxation of the Lower Oesophageal Sphincter (LES), a circular muscle at the base of the oesophagus that opens to allow food into the stomach but should close to prevent stomach content from "refluxing" back into the oesophagus. See the article in American Family Physician on "Evaluation and Management of Dypepsia."

Peptic Ulcer Disease

Peptic ulcer disease (PUD) includes irritation, ulcer formation and scarring of the stomach or the first part of the small intestine, called the duodenum. Ulcers of the stomach are often caused by irritating medications such as aspirin or other non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen. Stomach ulcers arising without provocative medications may precede stomach cancer. Ulcers of the duodenum are more common. They are not generally associated with cancer. Most duodenal ulcers have an infectious cause, contrary to earlier thoughts about the cause of these conditions.

Causes of Ulcers

Several factors are known causes of PUD and GERD. Previously, most ulcers were thought to be caused by irritants to the stomach, such as stress, spicy foods, caffeine, tobacco and alcohol. Alcohol in particular is an irritant to the lining of the stomach (mucosa). All of these can cause the circular muscle at the lower end of the oesophagus to relax and allow food to reflux from the stomach back into the oesophagus. This may contribute to heartburn and GERD, but other than alcohol, they do not contribute to most ulcers.

However, recent research demonstrates that most ulcers of the duodenum are caused by an infectious agent named Helicobacter pylori or H. pylori. According to the Centres for Disease control and Prevention, 90% of duodenal (small intestine) and 80% of gastric (stomach) ulcers are caused by H. pylori. Elimination of this bacteria frequently causes quick resolution of an ulcer and minimizes the chances of recurrence. People infected with this bacterium have two to six times increased risk of stomach cancer. This discovery led to a dramatic shift in the treatment of PUD. See the American Family Physician article - Patient Handout: "What Should I Know About Helicobacter pylori Infections?"

Symptoms of GERD and PUD

The diagnosis of GERD and PUD is important because not only is the disease potentially serious, but other conditions such as heart disease and gall bladder disease may be mistaken for GI irritation. There are many symptoms of PUD and GERD. Many people with GERD report a sour, brackish taste in their mouth after eating, particularly when lying down. Some will report a fullness in their lower chest similar to angina. People with ulcer disease may experience a burning sensation in their upper abdomen. Sometimes these symptoms are relieved temporarily by eating or taking antacids, but return in 30-60 minutes. People with bleeding ulcers may note dark, tar colored stools, fatigue or weakness. In rare cases, the blood loss may cause a loss of consciousness, particularly in a hypoxic environment with higher cabin altitudes. For this reason, bleeding ulcers are disqualifying for FAA certification until they are healed and the blood count has returned to normal.

Diagnosis

Physicians may also test the stool for blood using a card with stool placed on it. If blood is detected, suspicion for an ulcer increases. A blood test called the CLO test looks for evidence of H. pylori. A more expensive method of detecting H. pylori is the urea breath test. If either of these are positive, treatment to eliminate the H. pylori using two or three antibiotics is recommended. None of the above tests are definitive for ulcer disease.

A more specific test is an upper GI contrast study using a series of X-rays taken when an individual swallows a chalky liquid containing Barium. This study gives useful information regarding the function of the oesophagus and will outline most ulcers of the stomach and duodenum.

The most definitive study is an oesophagogastroduodenoscopy (EGD). The EGD involves lightly sedating an individual and using a flexible scope to visualize the oesophagus, stomach and duodenum. frequently the patient may watch the scope on a television monitor. The advantage of the EGD is that direct samples of ulcers and irritated tissue may be collected to study for cancerous changes. Samples for H. pylori may also be taken. Other less frequently used tests to study the esophagus include measuring pressures (manometry) and acid reflux (pH monitoring).

Treatment of GERD and PUD

Most physicians will treat a person with GERD or PUD symptoms conservatively in the initial stages. The individual will be instructed to avoid aspirin and similar pain medications, alcohol and tobacco. Frequently the individual has tried OTC antacids or H2 blocking medications. These H2 medications recently approved for OTC use include Zantac, Pepcid AC and Tagamet. If these provide partial relief, a prescription strength of the same medication may be used. These H2 blockers work by interfering with the secretion of stomach acid in response to food. Antacids such as Mylanta, Maalox, Tums and Rolaids neutralize acid that has already been secreted, but only act locally. The liquid preparations may be more effective than tablet forms.

Individuals diagnosed with an ulcer caused by H. pylori are generally treated with "combination therapy" including antibiotics.

Some medications used to treat acute ulcers include the antibiotics amoxicillin, metronidazole, tetracycline, and clarithromycin. Usually, two of these antibiotics are used in combination with an acid blocker, proton pump inhibitor and/or Pepto Bismol for a couple of weeks to treat ulcers caused by H. pylori.

Several compounds protect the lining of the stomach by various means. Carafate (sulcrafate) is a neutral starch compound that coats the stomach and protects the base of an ulcer or irritation. It is not absorbed by the body and its use does not require a waiver by the FAA if the ulcer is healed. Pepto-Bismol (bismuth subsalicylate) also coats the stomach and will kill H. pylori. It does not require a waiver from the FAA to use if there is no active ulcer. Cytotec (misoprostol) is a synthetic hormone-like substance called a prostaglandin. It both protects the lining of the stomach and inhibits acid production.

Acid production in the stomach is blocked by two categories of medications, the H2 blockers and the proton pump inhibitors. The H2 blockers include Tagamet (cimetidine), Zantac (ranitidine), Pepcid (famotidine), and Axid (nizatidine). These work by blocking the production of a type of histamine which normally would stimulate acid release into the stomach.

The proton pump inhibitors include Prilosec (omeprazole), Aciphex (raberprazole), Protonix (pantoprazole), Prevacid (lansoprazole), and Nexium (esomeprazole). They work by blocking an enzyme system in the cells that line the stomach and thus block the final stage of acid production. They are very effective in blocking acid released at baseline amounts as well as acid surges in response to foods. See an article in American Family Physician Proton Pump Inhibitors: An Update, July 15, 2002 for more information.

Ulcers caused by H. pylori usually respond to one to two weeks of "triple therapy" as noted above. This will eliminate the bacteria, but healing of the ulcer may take longer. Those without a demonstrable cause for their ulcer or with chronic reflux may be on long term acid blocking medication. Chronic use of these medications require reporting and clearance by the FAA, even if there is no ulcer.

FAA Reporting Requirements

FAA reporting should include documentation of how an ulcer was diagnosed, usually the report from the UGI or the EGD. Physician notes should document the treatment including type and dose of medication, lifestyle changes (stop alcohol, smoking or irritating medications) and the absence of symptoms. Blood counts should be normal to exclude anemia. A follow-up study (UGI of EGD) to demonstrate the absence of an ulcer after treatment, usually 3-6 weeks, strengthens the application to the FAA. Finally a statement regarding any long term medications and the absence of side effects should be included. The FAA will routinely require a "current status report form your treating physician" at the subsequent physical. The FAA protocol for PUD can be found in our Information Resources section.

Controllers placed on any of the medications described will need to get approval from the FAA Regional Flight Surgeon before returning to safety sensitive duty.

Reporting is generally made to the FAA Aeromedical Certification Division at:

Federal Aviation Administration
Aeromedical Certification Division
CAMI Bldg./ AAM-300
P.O. Box 26080
Oklahoma City, OK 73126-9922

Please note that clinical specialists may not fully address all of the aero medically significant issues. Often, erroneous or incomplete medical documentation can lead to significant delays in aeromedical certification.