Abdominal Pain in a Young Aviator -...

Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW-2013-2167, 9 May 2013 1

Calen N. Wherry, MD, MPH

Maj, USAF, MC, FS

Peter A. Baldwin, MD, MBA, MPH

Capt, USAF, MC, FS

USAF School of Aerospace Medicine

WPAFB, OH

RAM 2013

Abdominal Pain in a Young Abdominal Pain in a Young AviatorAviator


Disclosure InformationDisclosure Information84th Annual Scientific Meeting84th Annual Scientific Meeting

Drs. Calen Wherry and Peter BaldwinDrs. Calen Wherry and Peter Baldwin

We have no financial relationships to disclose.

We will not discuss off-label use and/or investigational use in our presentation.


• 23-year-old active duty RPA sensor operator with approx 25 flying hours all in the past 6 months

• TDY for initial training• Presented to military medical center ED while

TDY• Chief complaint – abdominal pain

Presenting HistoryPresenting History


• ED History• 2-day history of worsening abdominal pain and

fatigue; no recent change in diet; some change in stool

• Physical• Calm, but some distress• Abdomen: tender epigastrum, normal bowel

sounds• Some pallor to the skin



• Laboratory Studies• Hemocult card positive for blood• Hemoglobin 8, hematocrit 25• No other significant lab findings



• Due to critical H/H values, patient admitted to hospital and transfused

• GI consulted for evaluation of likely GI bleed• EGD revealed significant duodenal ulcer• Ulcer was coagulated during the endoscopy• Testing for Helicobacter pylori was negative• Patient placed on esomeprazole as well as iron

supplementation

TreatmentTreatment


Peptic Ulcer DiseasePeptic Ulcer Disease


• Further history revealed frequent use of Excedrin as well as energy drinks such as Red Bull and Monster

• Patient returned to home station for recovery• Tolerated PPI therapy and iron replacement

well• Repeat endoscopy 2 months after initial

presentation showed resolution of ulcer

Follow-Up CareFollow-Up Care


Aeromedical Aeromedical

ConsiderationsConsiderations


• 8% of Americans will develop an ulcer within their lifetime

• H. pylori is found in 80% of gastric ulcers and 90% of duodenal

• Smoking and NSAIDs also contribute to the formation or worsening of an ulcer

• Stress, caffeine, and spicy foods are only weakly related, mainly by aggravating symptoms and not the condition itself

Peptic Ulcer BackgroundPeptic Ulcer Background


• Cholecystitis, cholelithiasis, cholangitis, hepatitis

• Gastritis, gastroenteritis, GERD• Crohn’s (duodenal, unlikely gastric)• Zollinger Ellison syndrome: rare, multiple

ulcers, watery diarrhea, kidney stones• Appendicitis, acute abdomen

Differential DiagnosesDifferential Diagnoses


• History: Pain, nausea, or vomiting usually in-between meals with some relief from eating; frequent NSAID use

• Exam: Pain to palpation directly over lesion is sometimes noted

• Tests: Endoscopy for bleeding, persistent symptoms, or over the age of 55 (cancer risk); H. pylori (from blood, breath, stool, stomach tissue) culture

DiagnosisDiagnosis


• Antisecretory: H2 blockers, proton pump inhibitors

• Empiric Triple Therapy: PPI + clarithromycin + amoxicillin

• Endoscopy for hemostasis• Surgery if above fails or if possible

perforation; vagotomy, pyloroplasty, or Billroth I or II for persistent PUD

TreatmentTreatment


Healed Duodenal UlcerHealed Duodenal Ulcer


• Sudden incapacitation due to perforation or hemorrhage is of primary concern

• Chronic blood loss from PUD may lead to anemia; ulcer pain may be distracting and interfere with performance during critical phases of flight

Aeromedical ConcernsAeromedical Concerns


• USAF• AFI 48-123, Section 6I, Ground Based Controller

Standards• 6.46.12.2. Peptic ulcer disease or any complication

of peptic ulcer disease. An uncomplicated ulcer that has been inactive for 3 months and does not require medication (except the occasional use of antacids) is not disqualifying.

Aeromedical StandardsAeromedical Standards


• U.S. Army• AR 40-501, Chapter 4, Medical Fitness Standards

for Flying Duty• Paragraph 4-4, item d

• History of gastrointestinal bleeding



• U.S. Navy• Standards for enlistment and commissioning• Article 15-44, Abdominal Organs and

Gastrointestinal System• Section 2 Stomach and Duodenum

• B – Current ulcer of stomach or duodenum confirmed by x-ray or endoscopy is disqualifying

• C – History of surgery for peptic ulceration or perforation is disqualifying

Medical StandardsMedical Standards


• FAA• AME must defer to FAA for decision



• ICAO• Manual of Civil Aviation Medicine

• Chapter 3, para 3.3.7• An applicant with a history of one single episode of

bleeding as a complication may be assessed as fit if without symptoms for at least 8 weeks, if no medication is required, and if there is endoscopic evidence of healing. Assessment of fitness after recurrent bleeding episodes should be made based on a thorough investigation. The assessment should include 6 months of observation for bleeding or symptom return during the 3 years following a bleeding episode.



• The AMS for H. pylori positive and/or NSAID-associated peptic ulcer must include the following:

A. History and physical with note of presence or absence of ulcer complications (obstruction, perforation, or bleeding), and NSAID, tobacco, and alcohol use

B. Documentation of H. pylori status, treatment, and eradication (as applicable)

C. Documentation of cessation of NSAID use (as applicable)

D. Documentation of ulcer healing by confirmatory endoscopy

E. Report of current (returned to baseline) hemoglobin and hematocrit result

USAF Waiver RequirementsUSAF Waiver Requirements


F. Documentation that the aviator has been counseled about the warning symptoms of ulcer recurrence and complications (pain, melena, BRBPR, hematemesis, nausea and vomiting, lightheadedness, dyspnea on exertion)

G. Documentation that the aviator is asymptomatic without acid-suppressing medication (waiver may be considered on a case-by-case basis with chronic acid suppression therapy)

USAF Waiver Requirements USAF Waiver Requirements (cont.)(cont.)


• Aldoori WH, Giovannucci EL, Stampfer MJ, Rimm EB, Wing AL, Willett WC. A prospective study of alcohol, smoking, caffeine, and the risk of duodenal ulcer in men. Epidemiology. Jul 1997;8(4):420-4.

• Gisbert JP, Pajares R, Pajares JM. Evolution of Helicobacter pylori therapy from a meta-analytical perspective. Helicobacter. Nov 2007;12 Suppl 2:50-8.

• Pietroiusti A, Luzzi I, Gomez MJ, Magrini A, Bergamaschi A, Forlini A, et al. Helicobacter pylori duodenal colonization is a strong risk factor for the development of duodenal ulcer. Aliment Pharmacol Ther. Apr 1 2005;21(7):909-15.

• Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. Oct 1 2007;76(7):1005-12.

BibliographyBibliography


QuestionsQuestions


Backup SlidesBackup Slides


• Anemia of any etiology is also a disqualifying condition

• Hematocrit less than 40 (men) or 35 (women)• An appropriate work-up to prove no other

factors exacerbated the GI bleed may be beneficial (factor deficiencies, etc.)

• With a documented cause, the Waiver Guide suggests a stable hematocrit of at least 32

AnemiaAnemia ( AFI 48-123 6.44.18.1) ( AFI 48-123 6.44.18.1)


• Acetaminophen • Implicated in development of gastrointestinal

bleeding and perforation in both population-based studies and a randomized controlled trial

• The risk appears to be increased with the combination of NSAIDs plus high dose acetaminophen compared with either alone



• Aspirin• Irreversible inhibition of COX-1 and COX-2

• Eliminates mucosal prostaglandin production, leaving mucosa vulnerable to gastric secretion damage

• Decreases platelet adhesiveness by inhibiting a prostaglandin-initiated sequence necessary for platelet activation



• Aspirin (cont.)• Gastroduodenal toxicity may develop with low

dose cardiovascular prophylaxis.• Doses as low as 325 mg every other day increase

the risk of duodenal ulcers. In contrast to the stomach, damage to the duodenal mucosa by aspirin and NSAIDs seems to depend highly upon gastric acid.



• Rahme E, Barkun A, Nedjar H, et al. Hospitalizations for upper and lower GI events associated with traditional NSAIDS and acetaminophen among the elderly in Quebec, Canada. Am J Gastroenterol 2008;103:872-82.

• García Rodríguez LA, Hernández-Díaz S. Relative risk of upper gastrointestinal complications among users of acetaminophen and nonsteroidal anti-inflammatory drugs. Epidemiology 2001;12:570-6.

• Steering Committee of the Physicians' Health Study Research Group. Final report on the aspirin component of the ongoing Physicians‘ Study. N Engl J Med 1989;321:129-35.

• García Rodríguez LA, Lin KJ, Hernández-Díaz S, et al. Risk of upper gastrointestinal bleeding with low-dose acetylsalicylic acid alone and in combination with clopidogrel and other medications. Circulation 2011;123:1108-15.

BibliographyBibliography

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