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its adnexa, likely to cause incapacitation in flight, in particular any obstruction due to stricture or compression,
shall be assessed as unfit.
6.3.2.14.1 Recommendation.— An applicant who has undergone a major surgical operation on the biliary
passages or the digestive tract or its adnexa with a total or partial excision or a diversion of any of these
organs should be assessed as unfit until such time as the medical assessor, having access to the details of the
operation concerned, considers that the effects of the operation are not likely to cause incapacitation in flight.
It is, however, understood that a degree of interpretation and flexibility must always be exercised at the
discretion of the medical examiner and the medical assessor, taking into consideration not only medical
but also operational and environmental factors of relevance for the over-all evaluation of the medical
fitness of an applicant. In general, instances of acute or chronic intra-abdominal disease vary greatly in
severity and significance and will, in most cases, be cause for disqualification until after satisfactory
treatment and/or complete recovery.
Any condition causing acute abdominal pain of either intra- or extra-abdominal origin occurring in
connexion with aviation duties should be considered as “decrease in medical fitness” according to
Annex 1, 1.2.6.1. Such conditions are being reported frequently and are a common cause of in-flight crew
incapacitation. If or when surgical therapy is necessary, the provisions of 6.3.2.14 and the
Recommendation attached to it must be considered.
When assessing an applicant’s medical fitness with regard to the digestive system, the medical examiner
should in particular note the following conditions.
GASTRITIS
An important aetiological factor, often encountered in applicants with a history of gastritis, is the use or
abuse of alcohol as well as habitual use or misuse of “over-the-counter” pain-relieving drugs such as
aspirin. The use of antacids, which might indicate an underlying cause for subjective symptoms from the
digestive tract, should also be explored.
ICAO Preliminary Unedited Version — October 2008 III-3-2
PEPTIC ULCER
A common problem, which gives rise to special certification considerations, is peptic ulcer. Careful
examination and good clinical judgement are imperative in a realistic appraisal of any individual
situation. Certain generalizations would seem indicated, however, to serve as an over-all guide.
Uncomplicated peptic ulcer
Gastric ulcers are much less common than duodenal ulcers. Diagnosis is based on clinical symptoms and
gastro-duodenoscopy. More than 90 per cent of duodenal ulcers are caused by infection with helicobacter
pylori (H.pylori) It is possible to test non-invasively for H. pylori infection with a blood antibody test,
stool antigen test, or with the carbon urea breath test (in which the patient drinks 14C- or 13C-labelled urea,
which the bacterium metabolizes producing labelled carbon dioxide that can be detected in the breath).
However, the most reliable method for detecting H.pylori infection is a biopsy taken during endoscopy
with a rapid urease test, histological examination, and microbial culture. H. pylori should be eradicated to
allow the ulcer to heal. The standard first-line therapy is a one week “triple-therapy”: amoxicillin,
clarithromycin and a proton pump inhibitor such as omeprazole. Metronidazole may be used in place of
amoxicillin in those allergic to penicillin. This treatment of peptic ulcers will often cure the disease.
However, the proton pump inhibitor should be continued for at least another four weeks or until the ulcer
has healed; this may take up to eight weeks, sometimes even longer. If medication is repeatedly required,
a decision on medical fitness should be based on a thorough investigation with emphasis on ruling out
malignancy.
Pilots with uncomplicated peptic ulcer should be considered as unfit for all aviation duties during any
period of clinical activity sufficient to warrant treatment beyond simple dietary control. The general
criteria for medical fitness are that an applicant with a history of uncomplicated peptic ulcer be
symptom-free on a suitable diet and that there is endoscopic evidence of the ulcer healing. Irregular work
schedules and eating habits of flight crews on duty need to be considered as a complicating factor.
Complications
The most common complications of gastric or duodenal ulcer are: a) recurrence; b) bleeding; and
c) perforation.
Recurrence
Applicants suffering from ulcers complicated by chronicity, obstruction or haemorrhage should generally
be considered unfit for aviation duties, with the following exceptions:
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Manual of Civil Aviation Medicine 1(117)
