Clinical Practice Guideline
Developed for the
Aerospace Medical Association
by their constituent organization
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
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
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.
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March 19, 2007