A burning issue

Both the IFA and the underwriter will commonly encounter disclosures regarding gastro-oesophageal disorders, a term that encompasses many different conditions including oesophagitis, acid indigestion, hiatus hernia, ulcers and gastritis. With modern lifestyle meaning more stress at work, less leisure time, hectic lifestyles and poorly balanced diets it is no wonder that the body's digestive system struggles to cope. Once seen as a disease of the middle-aged this is now more commonly seen in the 20s and 30s. The most common condition encountered is gastro-oesophageal reflux disease (GORD).

So what is GORD? The oesophagus is a muscular tube approximately 25cms in length connecting the pharynx to the stomach. Oesophagitis is an inflammation of the lining of the oesophagus. This is mostly caused by the digestive juices repeatedly moving upward from the stomach into and making prolonged contact with the lower oesophagus. The normal muscle contraction, which is supposed to keep the lower end of the oesophagus closed, fails due to muscle weakness and this is when this reflux occurs. There is no known cause for this muscle weakness. A hiatus hernia where a small part of the stomach protrudes into the chest above the diaphragm may also prevent the oesophageal muscles from working properly thus causing reflux.

The symptoms caused by this reflux include a burning sensation in the throat; this is because the oesophagus does not have the same protective lining that the stomach has. This can be worse at night when lying flat or can be aggravated by alcohol, hot drinks or a heavy meal. Food can actually regurgitate into the mouth. In its most severe forms ulceration can cause pain, scarring and narrowing, making swallowing more difficult.

Barrett's oesophagus

Barrett's oesophagus is a long-term complication of chronic reflux oesophagitis. The normal lining of the oesophagus - rather than recovering as in the majority of oesophagitis sufferers - shows changes from squamous to glandular epithelium. These changes need to be regularly monitored as although it may be no more symptomatic than usual GORD it is a pre-malignant condition, which increases the risk of cancer of the oesophagus. The specialist may decide to monitor these changes every one, two or three years via an endoscopy, depending on the extent of the changes and how much of the oesophagus is involved.

Diagnosis, investigations and treatment

GORD is a clinical diagnosis in the main based on symptoms alone and many patients can be treated without investigation. Also, due to the prevalence of the condition it is not possible to refer all sufferers for investigation and selection criteria will depend on factors such as the patient's age and severity/persistence of symptoms. Priority is likely to be given to those aged 45 or over.

Simple measures such as eating small meals regularly rather than large meals, not eating late at night, losing weight and exercising more can help reduce the symptoms. Medical treatment aims to either neutralise acid in the oesophagus with simple antacids or stronger treatment such as zantac or protium to reduce or even stop acid in the stomach. Short-term treatment may be all that is needed although repeat courses may be needed to treat further episodes. A minority of patients may need long-term permanent treatment.

The GP might decide that investigation is needed, and he will almost certainly arrange investigation if the symptoms are severe and persist despite medication, if only to rule out any serious underlying cause for the symptoms.

The investigation of choice is an endoscopy, where a narrow flexible tube is passed through the mouth and throat on to the oesophagus. The specialist will look for any areas of ulceration or reddening, small biopsies can be taken if the specialist feels this is necessary and this will often be the case if Barrett's is suspected.

Other investigations are barium swallows, where a barium fluid is swallowed and areas of ulceration or narrowing are looked for on x-ray. 24-hour measuring of acidity levels can also be performed. Quite regularly testing is made for helicobacter pylori, which is an organism that is associated with excess acid secretion. If this test proves positive eradication therapy is given to the patient.

Surgical treatment is rarely used but if symptoms are severe and there is a hiatus hernia, keyhole surgery may be performed to tighten the tissue around the lower oesophagus in order to decrease or prevent reflux. If there is significant narrowing of the oesophagus this can be widened via endoscopic procedure, although there is a high risk of recurrence with regular repeat procedures being needed.

Simon Taylor is a senior underwriter with Scottish Equitable Protect

Underwriting implications

The underwriter will be looking for specific information to be able to assess the risk. How long have the symptoms been present, have they ever been investigated or are any investigations planned? If so, what investigations were performed and what were the results? Has Barrett's been confirmed or ruled out? Does the applicant remain under the care of the specialist or has he/she been discharged back to the care of the GP? What treatment, if any, are they on?

If the applicant has had investigations and remains under the specialist's care this may well indicate that Barrett's is present and requires regular surveillance. The underwriter is likely to request a GP's report (GPR) with details of the specialist's findings and opinion. If investigation is awaited then it is highly likely that the results will have to be awaited before terms can be considered.

If all investigations were normal and the applicant has been discharged even if still taking treatment for the symptoms then terms may be available without the need for a GPR. If the IFA can obtain comprehensive details at the time of the application this will help the underwriter and may avoid the need for a report from the GP.

The majority of applications with a history of uncomplicated GORD, even if still being treated, are likely to be accepted at standard rates for all benefits. Where Barrett's oesophagus is involved a small loading may be applied to all the benefits and/or an exclusion applied to critical illness cover, where no claim would be paid in the event of gastro-oesophageal cancer.

The IFA may take advantage of an underwriting helpline to discuss the case with an underwriter before submitting the application.

GORD: the statistics

• GORD is likely to be present if heartburn symptoms are experienced two or more days a week. This occurs in 23% of the adult population.

• Up to 40% of people suffer from GORD symptoms but only 10% of these seek their GP's advice.

• There are approximately 8 million sufferers worldwide.

Source: www.astrazeneca.com

• In the UK in 1994, £400 million was spent on 'ulcer healing/GORD' drugs.

• 4% of GP consultations are for GORD.

• 2% of the entire adult population receive either an endoscopy or barium meal each year.

• Only 10% of those seeing their GP will be referred for consultation or investigation.

• 210 consultations per GP each year are for GORD, which exceeds the availability for diagnostic procedures.

Source: www.bsg.org.uk

• One in three adults experience heartburn symptoms every few days, one in 10 experience them every day.

• Regular symptoms are more common in smokers, pregnant women, heavy drinkers, the overweight and those aged 35-64.

Source: www.patient.co.uk

• Hiatus hernia occurs in approximately 30% of people over 50 although it is not always associated with GORD symptoms.

Source: Kumar & Clark 'Clinical Medicine'