Abdominal Pain in a Young Aviator

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1 Abdominal Pain in a Young Aviator 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

2 Disclosure Information 84th Annual Scientific Meeting Drs. 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. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

3 Presenting History 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

4 Presenting 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

5 Presenting History Laboratory Studies Hemocult card positive for blood Hemoglobin 8, hematocrit 25 No other significant lab findings Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

6 Treatment 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

7 Peptic Ulcer Disease Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

8 Follow-Up Care 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

9 Aeromedical Considerations Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

10 Peptic Ulcer Background 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

11 Differential Diagnoses 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

12 Diagnosis History: Pain, nausea, or vomiting usually inbetween 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

13 Treatment Antisecretory: H 2 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

14 Healed Duodenal Ulcer Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

15 Aeromedical Concerns 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

16 Aeromedical Standards USAF AFI , Section 6I, Ground Based Controller Standards 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. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

17 Aeromedical Standards U.S. Army AR , Chapter 4, Medical Fitness Standards for Flying Duty Paragraph 4-4, item d History of gastrointestinal bleeding Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

18 Medical Standards 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

19 Aeromedical Standards FAA AME must defer to FAA for decision Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

20 Aeromedical Standards ICAO Manual of Civil Aviation Medicine Chapter 3, para 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. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

21 USAF Waiver Requirements 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

22 USAF Waiver Requirements (cont.) 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) Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

23 Bibliography 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): 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 ;21(7): Ramakrishnan K, Salinas RC. Peptic ulcer disease. Am Fam Physician. Oct ;76(7): Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

24 Questions Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

25 Backup Slides Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

26 Anemia ( AFI ) 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

27 Peptic Ulcer Background 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

28 Peptic Ulcer Background 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 Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

29 Peptic Ulcer Background 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. Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

30 Bibliography 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: García Rodríguez LA, Hernández-Díaz S. Relative risk of upper gastrointestinal complications among users of acetaminophen and nonsteroidal anti-inflammatory drugs. Epidemiology 2001;12: 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: 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: Distribution A: Approved for public release; distribution is unlimited. Case Number: 88ABW , 9 May

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