Clinical Practice Guideline

For

GASTROESOPHAGEAL REFLUX DISEASE

Developed for the

Aerospace Medical Association

by their constituent organization

American Society of Aerospace Medicine Specialists

Overview: Gastroesophageal reflux disease (GERD) includes the constellation of symptoms and sequelae which occur as a result of abnormal reflux of gastric contents into the esophagus. Gastroesophageal reflux (GER) is a multifactorial process, with transient lower esophageal sphincter (LES) relaxation felt to be the key motility disorder in mild to moderate disease. It is estimated that 40% of the U.S. population experiences symptoms of GER at least once a month, with 7% experiencing symptoms daily. The most common symptoms of GERD are pyrosis and regurgitation. Other symptoms may include dysphagia, odynophagia, water brash, chest pain and hemorrhage. Pulmonary symptoms may be the only clinical manifestations of GER and include chronic cough, wheezing, asthma, hemoptysis, hoarseness and recurrent aspiration pneumonia. The presence of GER is suggested by history, whereas the presence and complications of reflux esophagitis are most commonly assessed through endoscopy. Endoscopy may be normal in many patients with GER (up to 40%) or may reveal erosive esophagitis, peptic stricture, columnar cell-lined lower esophagus (Barrett’s esophagus), or adenocarcinoma. The presence of alarm symptoms, such as dysphagia, weight loss, and bleeding, suggest more complicated disease and warrant endoscopic investigation. The differential diagnosis of GERD includes peptic ulcer disease, gastritis, symptomatic gallstones, and NSAID-induced GERD, all of which should be at least briefly considered in the dyspeptic patient. Mildly symptomatic cases could benefit from lifestyle changes prior to pharmacologic interventions. Obesity is strongly correlated to GER, through a variety of mechanisms, and should be a focus of non-pharmacologic intervention. Additional conservative treatment measures include the avoidance of fatty foods, chocolate, and carminatives (spearmint, peppermint). Alcohol and smoking can decrease LES pressure and/or delay gastric emptying which can cause/worsen symptoms of GER. Nonsteroidal anti-inflammatory drugs can be caustic to the esophageal mucosa, these agents should also be avoided. Patients should also be taught to avoid wearing tight clothing, eating large meals, and reclining soon after eating.

First line pharmacologic therapy involves the use of antacids; the most effective being those containing a combination of magnesium and aluminum hydroxides. Most individuals with heartburn or regurgitation not responding to conservative measures and intermittent antacids will self-medicate with over-the-counter (OTC) histamine 2 (H2)-receptor antagonist regimens (ranitidine or famotidine), or even proton pump inhibitors (PPIs) such as Prilosec OTC. The availability of potent OTC meds is a concern for flight surgeons, since patients with potentially severe GERD can self-medicate, gaining symptom relief, even though their clinical condition could be of aeromedical concern.

Disease severe enough to warrant physician attention can be treated with higher dose H2-receptor antagonists, or with a PPI (omeprazole, rabeprazole, lansoprazole, pantoprazole). Although a prokinetic agent such as metoclopramide is sometimes used clinically, its potential for side effects poses an unacceptable risk to flight safety. In resistant and complicated cases of GERD, antireflux surgery may be considered. Nissen fundoplication, the preferred antireflux procedure, reinforces the lower esophageal sphincter with a 360-degree gastric wrap around the lower esophagus. Nissen procedures can now be done through laparoscopy or thoracoscopy. Major complications of GERD include esophageal strictures, ulceration with or without hemorrhage, and the development of Barrett’s esophagus. Any of these complications should prompt referral to a gastroenterologist for further evaluation and treatment.

Aeromedical Concerns: Increases in intra-abdominal pressure, changes in gravitational position, and abdominal muscle contraction all increase the pressure gradient between the abdomen and the thorax, worsening the symptoms of GERD. This is of major concern in the high-performance cockpit. Reflux symptoms are of aeromedical concern because they can distract the aircrew member, though they are usually not disabling. The availability of OTC medications can mask symptoms of severe disease until the flyer presents with significant medical complications such as hemorrhage or strictures. Acute hemorrhage secondary to mucosal ulcers may occur in aircrew with chronic GERD and severe esophagitis, and can be disabling. Acute esophageal obstruction, caused by food impaction in the face of a peptic stricture, can also be disabling. In addition, medications used to control GERD may cause disqualifying side effects. Metoclopramide, a dopamine antagonist, crosses the blood-brain barrier and up to 20% of patients experience psychotropic side effects to include somnolence, lassitude, restlessness, anxiety, insomnia, and rarely extrapyramidal reactions. Cisapride, also a dopamine antagonist, is better tolerated, but is still associated with psychiatric and extrapyramidal symptoms; furthermore, QT prolongation and serious ventricular arrhythmias have been a particular problem with this drug. Sucralfate, an aluminum sucrose polysulfate, potentiates cytoprotection and mucosal resistance and is safe to use in initial and maintenance therapy, though its efficacy is limited. Antacids are also safe to use in an aeromedical environment. Some H2-receptor antagonists and PPIs are well-tolerated and may generally be used in aviators, although waiver may be required for military flyers.

Aeromedical Disposition (military): Each branch of service has policies regarding GERD in candidates for aircrew positions and in established flyers. In general, symptomatic GERD currently requiring medication is disqualifying. However, in the Army, only cases demonstrating certain “warning symptoms” require waiver, while the Navy and Air Force have somewhat more stringent requirements. In addition, use of medications other than occasional OTCs is generally disqualifying. Waivers are generally considered favorably provided symptoms can be adequately controlled and medications tolerated without detrimental side effects. Chronic use of antacids, sucralfate, H2 blockers, and PPIs may be considered for waiver. Anti-motility agents are not waiverable. Flights surgeons should refer to the medical standards and waiver guides for their respective branches of service for specific information regarding waiver policies and requirements.

Aeromedical Disposition (civilian): The Federal Aviation Administration (FAA) does not specifically mention GERD or esophagitis as disqualifying conditions, nor does it place limitations on specific medications used to treat GERD. However, the aviation medical examiner must exercise medical judgment to determine whether the severity and/or frequency of symptoms, or the medications used to relieve symptoms, pose a risk or potential risk to aviation safety. Questionable cases should be deferred to the FAA for decision.

The FAA does not require an airman to possess an authorization for special issuance (waiver) for GERD unless they have had moderate to severe symptoms. All medications for the exception of metoclopramide and Cisapride are permitted. The airman must report any continuous use of medications to the FAA.

Experience: A review of the US Air Force Aeromedical Information Management Waiver Tracking System (AIMWTS) revealed that from June 2001 to Feb 2007, 109 waiver requests were submitted with the diagnosis of GERD and 95 were approved for an approval rate of 87% in Air Force aviators.

References:

1. Cappell MS. Clinical presentation, diagnosis, and management of gastroesophageal reflux disease. Med Clin N Am. 2005; 89:243-291.

2. Eastwood GL, Avunduk C. Gastroesophageal reflux disease. Manual of Gastroenterology. 1988; 1:104-15.

3. Goyal RK. Diseases of the esophagus. Isselbacher KJ, Braunwald E, Wilson JD, Martin JB, Fauci AS, Kasper DL (eds). Harrison’s Principles of Internal Medicine. 1994; 13:1355-63.

4. Rayman RB, et al. Clinical Aviation Medicine. 2006; 2:13-14.

5. Robinson M. Prokinetic therapy for gastroesophageal reflux disease. American Family Physician. 1995; 52(3):957-62.

March 19, 2007