Being a military veteran is characterized by a number of positive and negative aspects. On the one hand, I am proud of my past service and the contributions I was able to make. On the other hand, I cannot get rid of the fact that serving in the military has affected my health considerably. Today, I continue suffering from persistently recurrent epigastric distress for gastroesophageal reflux disease (GERD). I was first diagnosed with GERD by Dr. Smita S. Shah at Alabama Digestive Disorders Center in February 2018. This information can be found in my civilian medical records. However, the history of this condition can be traced back several decades ago, which allows understanding its progress and impact on my routine activities and the life quality in general.
My initial concerns began earlier, in April 1984, when I addressed a local hospital with a chief complaint of gastrointestinal (GI) discomfort that had been lasting during the last 7-10 days. At that moment, I observed a slight loss of appetite, and stomach upset returned from time to time. Additional problems included constipation, heartburn, and painful swallowing. A physical examination proved stomach pain and tenderness. The diagnosis I was given was probable gastritis, and the doctor prescribed Maalox. The goal of the treatment was to relieve symptoms of pyrosis and manage the possible progress of stomach inflammation due to gastritis. I was not properly informed about the side effects of this medication, including the possibility of constipation, nausea, and diarrhea. Still, I observed certain improvements and controlled painful sensations in my stomach with the help of Ibuprofen since 1975.
My next visit to the Troop Medical Clinic with a complaint of abdominal pain was in September 1990. The same diagnosis, gastritis, was given, and my status was changed to chronic. I was prescribed the same medications as before, and I followed the prescription directly. I tried not to focus on pain and used the medications that would help me get this condition under control. Still, it was hard to neglect some pain episodes, which provoked negative feelings and concerns.
Similar episodes repeated in 2011 and 2012, but the number of problems was considerably increased. I reported knee and elbow joint pain, vision problems (myopia and cataract), foot pain, back pain, and arthritis. A full list of problems can be found in my health records. Active medications included Ibuprofen (600 mg), Propranolol (60 mg), Cephalexin (500 mg), and Omeprazole (20 mg). Despite a properly developed pharmacological treatment plan, I continued experiencing reoccurring issues with my stomach.
In 2018, Dr. Shah performed an upper GI endoscopy due to the indications for epigastric abdominal pain. The findings were a normal upper third of esophagus and middle of third of esophagus, LA Grade A esophagus with no bleeding, diffuse moderate inflammation (erythema in the lower third of esophagus), and a 2 cm hiatal hernia. GERD was a diagnosis this time, which explained chronic stomach acid, heartburn, dysphagia, and irregular constipation. A new treatment plan included Omeprazole (20 mg) and the already prescribed antacids that were effective for managing GERD symptoms.
In general, this condition has a significant impact on my life. Due to constantly developing signs and health problems, I was not able to eat everything I wanted and had to follow specific dietary habits. At this moment, I am concerned that my GERD is secondary, and it was exacerbated by military service and/or aggravated by my service-connected unspecified depressive disorder and the medications I was prescribed.
It is at least as like as not (a 50%>/50% probability) that the veteran’s current gastroesophageal reflux disease (GERD) diagnosis is secondary to, related to, and/or aggravated by the individual’s service-related Unspecified Depressive Disorder (F32.9) with anxious distress. In this case, the veteran is seeking service connection to his GERD provoked by depression and anxiety. The evidence obtained from current studies and veteran statistics should prove the importance of the discussion.
Rationale and Nexus to Support Medical Opinion
Symptoms and Epidemiology
GERD is one of the common chronic conditions when people suffer from stomach pain caused by gastric acid in the esophagus. According to the U.S. Department of Veteran Affairs (2020), about 1 in 5 American adults are diagnosed with GERD. Although it is more likely for women aged 30-60 years to have this disease, men also become chronic patients frequently. In this analysis, the patient was first diagnosed with GERD at Alabama Digestive Disorders Center in February 2018. Symptoms of the disease included recurrent epigastric distress, heartburn, dysphagia, regurgitation, substernal chest, arm, and shoulder pain, constipation, and general gastrointestinal (GI) discomfort. In addition to the already prescribed Ibuprofen (every four hours as need with food), antacid (Maalox), and other inhibitors, antidepressants, and beta-blockers (Metoprolol, Pravastatin, Bupropion, Trazodone, and Terazosin), Omeprazole was obligatory to control GERD.
The digestive system of a human is complex in terms of its structure and functions. It consists of the GI tract, namely the esophagus, stomach, and small/large intestines, and accessory organs, i.e., liver, gall bladder, and pancreas (Kong et al., 2018). There are three main functions to be completed regularly: food digestion, nutrient absorption, and waste elimination (Kong et al., 2018). Digestion means the possibility of the body to move food from the mouth to the small intestine. Such processes as chewing and swallowing make food appropriate for the system where digestive juices break down large pieces. In the lower esophageal sphincter, the muscle relaxes and passes food to the stomach. However, if stomach acid returns to the tube that unites the mouth and the stomach (this process is defined as acid reflux), the esophagus gets irritated and provokes additional inflammation. These changes provoke so-called “classic” symptoms of heartburn and GI discomfort (Clarrett & Hachem, 2018). It is not always easy to identify all the symptoms and address medical help quickly, and people continue developing GERD by taking pain killers and antacids.
Healthcare providers recommend regular checkups for veterans to prevent the development of GERD-related complications. If this condition remains untreated for a long period, patients are challenged by severe conditions like esophagitis, Barrett’s esophagus (precancerous change), and esophagus ulcers (Clarrett & Hachem, 2018). Erosions grow fast and result in GI bleeding, which provokes anemia and melena. Barrett’s esophagus is dangerous because of the replacement of squamous cell epithelium with columnar epithelium and goblet cells and the possibility of malignant transformations (Clarrett & Hachem, 2018). Cancer is difficult to treat, and it is important for patients who are at risk of GERD to control their habits and make regular assessments.
In the majority of cases, the main risk factors of GERD include obesity, delayed emptying, and smoking. For example, obesity increases abdominal pressure and reduces the lower esophageal sphincter pressure (Argyrou et al., 2018). Smoking is also related to GERD, and researchers find about 37% risk in women and 58% risk in men (as cited in Argyrou et al., 2018). When people eat at night or use fatty or fried foods, they expose themselves to additional problems. If a person needs to take medication, drugs like pain-killers or antidepressants have a negative impact on the digestive system. Finally, the psychological status of an individual may predetermine GERD and its progress (Choi et al., 2018). Depression and anxiety play an important role in developing a treatment plan for GERD patients.
Mental Health Pathophysiology
Mental health may be challenged by a variety of disorders characterized by similar symptoms like depressed mood, problematic thinking, and unexplained worries. In this case, the patient is diagnosed with depression and anxiety after military service. Hester (2017) focus on these mental health conditions in veterans as the outcomes of questionable employment prospects, lost purposes, and family crisis. Additional psychopathological changes include fatigue, lack of energy, and sleep disturbances. Murri et al. (2019) introduce several mechanisms related to depression and anxiety: low physical activities (a sedentary lifestyle), poor dietary regimens, and dysregulation of homeostatic systems. Depression has a negative impact on the work of the hypothalamic-pituitary-adrenocortical (HPI) axis and the autonomic nervous system (Murri et al., 2019). With age, depression may explain vision problems, hearing difficulties, breathlessness, and high blood pressure (Kang et al., 2017). Although the symptoms of depression usually influence the emotional state of a patient, the complications of this disorder touch upon many physical functions.
There is a relationship between the depressed and anxious mood of patients who are currently diagnosed with GERD. On the one hand, GERD may provoke depression because the esophageal mucosa reveals cytokines and bronchoconstriction that result in upregulation, inflammation in the central nervous system, and sleep disorders (Kim et al., 2018). On the other hand, depression increases the GERD risks as psychological changes reduce the body sensation and decrease the lower esophageal sphincter pressure (Kim et al., 2018). Finally, antidepressants can aggravate reflux and delay gastric emptying, which is proved by constipation and GI discomfort (Kim et al., 2018). All these characteristics have to be carefully assessed in patients either with GERD or depression not to promote new comorbidities.
Medical Literature Studies on GERD and Mental Health Problems
To prove the impact of depression on GI disorders, many researchers continue conducting studies and explain the connection of physical and psychological problems. As cited in Kim et al. (2018), depression is commonly diagnosed in 7.6% of Americans and 11% of UK citizens. GERD and its complications are revealed in more than 20% of European and American populations, with increased ratings in East and Asian countries (as cited in Argyrou et al., 2018). A significant association between anxiety and GERD is reported by Choi et al. (2018). However, one should remember that 50% of patients with GERD live asymptomatically, meaning that doctors and individuals are not able to relate GI discomfort with depression in all patients’ cases (Choi et al., 2018). In addition, GERD is not always timely diagnosed because of its similarity with gastritis symptoms. If a person is present with GI discomfort and heartburn as the chief complaints, doctors diagnose gastritis and prescribe antibiotics and inhibitors to reduce acid levels (Choi et al., 2018). Still, gastritis challenges the stomach, while GERD irritates the esophagus, which causes treatment and complication differences.
Regarding the nature of the relationship between GI and mental health disorders, numerous research projects are developed to help medical workers pay attention to specific physiological and emotional changes. Argyrou et al. (2018) define GERD as a multivariate disorder due to its comorbidities and dependence on generic and environmental factors. According to Kim et al. (2018), depression and GERD continue displaying bidirectional associations, and it is hard to realize either GERD contributes to depression or vice versa. In any case, this relationship is evident, and regular checkups are required. Clarrett and Hachem (2018) base their study on the fact that depression is a common risk factor for GERD, and if such symptoms as delayed gastric emptying are observed, GI examination should be done. Medical records, communication with patients and their families, attention to recent psychological and physiological changes play a vital role in diagnosis and the healing duration.
Summary and Conclusion
GERD is a medical condition that is related to military service in a patient. The goal of this nexus letter was to prove that, in this case, GERD is secondary to depression and anxiety that were diagnosed several years ago. At this moment, enough evidence can be found to show how the chosen GI condition may be caused by mental health changes. The review of medical records, communication with the patient, and the analysis of current literature help obtain a clear picture of the situation. Military service is characterized by a number of benefits and positive contributions to an individual and society. However, the health complications cannot be ignored, and the GERD condition may be chronologically developed without symptoms. At this moment, the patient needs services for his GERD condition as secondary to depression and anxiety aggravated by his military service.
Argyrou, A., Legaki, E., Koutserimpas, C., Gazouli, M., Papaconstantinou, I., Gkiokas, G., & Karamanolis, G. (2018). Risk factors for gastroesophageal reflux disease and analysis of genetic contributors. World Journal of Clinical Cases, 6(8), 176-182.
Choi, J. M., Yang, J. I., Kang, S. J., Han, Y. M., Lee, J., Lee, C., Chung, S. J., Yoon, D. H., Park, B., & Kim, Y. S. (2018). Association between anxiety and depression and gastroesophageal reflux disease: Results from a large cross-sectional study. Journal of Neurogastroenterology and Motility, 24(4), 593-602.
Clarrett, D. M., & Hachem, C. (2018). Gastroesophageal reflux disease (GERD). Missouri Medicine, 115(3), 214-218.
Hester, R. D. (2017). Lack of access to mental health services contributing to the high suicide rates among veterans. International Journal of Mental Health Systems, 11.
Kang, H. J., Bae, K. Y., Kim, S. W., Shin, H. Y., Shin, I. S., Yoon, J. S., & Kim, J. M. (2017). Impact of anxiety and depression on physical health condition and disability in an elderly Korean population. Psychiatry Investigation, 14(3), 240-248.
Kim, S. Y., Kim, H. J., Lim, H., Kong, I. G., Kim, M., & Choi, H. G. (2018). Bidirectional association between gastroesophageal reflux disease and depression: Two different nested case-control studies using a national sample cohort. Scientific Reports, 8(1).
Kong, S., Zhang, Y. H., & Zhang, W. Regulation of intestinal epithelial cells properties and functions by amino acids. BioMed Research International, 2018.
Murri, M. B., Ekkekakis, P., Magagnoli, M., Zampogna, D., Cattedra, S., Capobianco, L., Serafini, G., Calcagno, P., Zanetidou, S., & Amore, M. (2019). Physical exercise in major depression: Reducing the mortality gap while improving clinical outcomes. Frontiers in Psychiatry, 9.
U.S. Department of Veteran Affairs. (2020). Gastroesophageal reflux disease (GERD). VA.gov. Web.