ulcers and reflux disease (GERD)
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.
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
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
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
Controllers placed on any of the medications described will need to get
approval from the FAA Regional Flight Surgeon before returning to safety
Reporting is generally made to the FAA Aeromedical Certification Division
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.