Making sense of digestive problems

Our digestive systems are complex and liable to many disorders. Studies have shown that one person in 10 dies from a digestive-related disorder.

Most of these disorders are troublesome but do not shorten life, but others are potentially dangerous and can be fatal.

The term digestion describes the body's system for the breakdown and absorption of food. It consists of the gastrointestinal (GI) tract, which is a tube extending from the mouth to the anus. It contains food from the time it is eaten until it is digested and then absorbed or prepared for elimination. The GI tract includes the mouth, pharynx, oesophagus, stomach and the small and large intestine.

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most common gastrointestinal disorder. Symptoms vary greatly from person to person but usually include cramping, abdominal discomfort, bloating and a change in bowel habit ' either constipation or diarrhoea. It is reported that a third of people in Britain have occasional symptoms of IBS and one in 10 has symptoms bad enough to seek medical attention. Although symptoms can be troublesome and persistent IBS does not lead to serious complications. Anxiety-related illnesses are commonly associated with IBS and in cases where this is apparent the underwriter would be more concerned with the underlying mental disorder. IBS is often diagnosed when investigations such as colonoscopy (fibre optic camera observation of the colon) have ruled out more serious diseases.

Inflammatory bowel disease

Inflammatory bowel disease (IBD) is the general name for diseases that cause inflammation of the intestines. The two most common disorders in this category are ulcerative colitis and Crohn's disease.

Ulcerative colitis

This is where the lining of the large bowel (colon) becomes inflamed and ulcerated. The main symptoms are attacks of bloody diarrhoea, abdominal pain and a general feeling of tiredness. A severe attack of ulcerative colitis can be life threatening. The extensive inflammation causes blood loss (with anaemia) and nutritional deficiencies. The colon wall may thin and then expand to produce a toxic dilation and/or perforation. Both of these have a high fatality rate and 5% of people with ulcerative colitis develop cancer of the colon. This risk increases with duration and extent of colon involvement. In cases where the entire colon is involved the risk may be 32 times the normal range. In its most severe form complications can include joint problems, liver disease, eye disorders and inflammation of the aorta.

For most patients, the disease can be controlled by a combination of drugs. Active disease is treated with short courses of steroids followed by long-term use of sulphasalazine or mesalazine to keep the disease in remission. Steroids are not recommended for long-term use due to unwanted side effects which can include peptic ulceration, high blood pressure, diabetes and osteoporosis (brittle bones). Surgery may be required in severe cases and the disease can be cured by the removal of the colon.

Ratings will depend on the severity of the disease and number of years since the last attack. Terms will be more favourable in cases where the disease is limited to the rectum or sigmoid colon only. As a guide, cases of ulcerative colitis classed as mild may attract a loading of around +75/100% on life cover when symptomatic within the last year. Standard terms can be considered in cases where there have been no recurrences for five years and in cases where successful surgery has been performed with no further symptoms. In more severe cases where the entire colon is involved, these ratings can increase to +175/250%.

For critical illness cover, ratings can range from +50 to +150% depending on the risk factors identified. The underwriter may wish to exclude cancer of the colon. This benefit may be declined in severe cases.

Crohn's disease

Like ulcerative colitis, Crohn's disease also tends to be a life-long problem and symptoms are similar. This disease can affect any part of the GI tract from the mouth to the anus, although the ileum (part of the small bowel) is most commonly affected. It runs an unpredictable course but is typically chronic and relapsing. The younger the individual is diagnosed, the greater the chance of recurrence.

The most common complication associated with Crohn's disease is blockage of the intestine due to thickening and scarring of the intestinal wall. Extra-colonic manifestations similar to those seen in ulcerative colitis may cause further complications.

Mortality results have improved in recent years with advances in both surgical and medical treatment. The main excess mortality is found in individuals with small bowel disease and those with stomach and duodenal involvement.

Treatment again consists of short courses of steroids followed by main-tenance therapy in the form of sulphasalazine to control inflammation. Many patients with Crohn's disease require surgical intervention to remove severely diseased areas of bowel and to treat complications.

The rating method is similar to colitis. Individuals under 35 who have had symptoms within the last year can expect ratings up to +200%. Ratings will reduce the longer the applicant remains symptom free. Standard terms can be considered in cases where there have been no relapses in over five years and in cases where successful surgery has been performed and there have been no recurrences for over two years. Additional ratings may be added for any associated complications. Critical illness can be considered with ratings of up to +150% but applications may well be declined if the disease has been active within the last two years.

Sickness related benefits will be given individual consideration for both ulcerative colitis and Crohn's disease and where terms are available will attract a rating or exclusion.

Gastro-oesophageal reflux disease (GORD)

Gastro-oesophageal reflux is the process of reflux of digestive juices in the stomach into the oesophagus, occurring typically after eating. Almost everyone experiences this at some time. The usual symptom is heartburn, commonly occurring after a meal. However, in some individuals reflux is frequent or severe enough to cause more significant problems and can be considered a disease.

As well as heartburn, reflux can cause inflammation of the lining of the oesophagus (oesophagitis). Discomfort may be felt after eating, especially rich, acidic, spicy or fatty foods. In severe cases the lining of the oesophagus becomes ulcerated and painful and the individual may even experience difficulty in swallowing.

GORD has been associated with smoking, obesity, increased alcohol intake and the use of non-steroidal anti-inflammatory drugs. Sometimes reflux is due to a hiatus hernia which is the protrusion of a small part of the stomach above the diaphragm into the chest.

Treatment is a combination of lifestyle changes and medication. Quitting smoking, avoiding large meals and losing weight may help to relieve symptoms. Medicines range from simple antacids through to stronger drugs which reduce the production of acid in the stomach. In severe cases keyhole surgery may be performed to tighten the tissue around the oesophagus and reduce reflux.

Barrett's oesophagus

Barrett's oesophagus is a complication of long-standing oesophagitis. This condition is an alteration in the normal mucosal lining of the oesophagus and is termed a pre-malignant condition. There is an increased risk of oesophageal cancer in these individuals. Once Barrett's has been diagnosed the GP will advise regular endoscopies to detect any malignant changes. The underwriter will take a cautious approach in such cases and benefits will probably be postponed until the results of any outstanding investigations are known.

In cases of confirmed Barrett's, terms may be available with a small rating of +50% extra mortality on life and an exclusion for gastric or oesophageal cancer on critical illness.

Peptic ulcers

Peptic ulcer is the name used to describe an ulcer occurring anywhere in the alimentary tract. The most common are duodenal and gastric ulcers. In Britain about one in 10 men and one in 15 women suffer from an ulcer at some time in their lives, but in most people they heal up with treatment.

The main causes of peptic ulceration are helicobacter pylori infection and non-steroidal anti-inflammatory drugs such as aspirin. Smoking and heavy alcohol intake have also been implicated. Symptoms include dyspepsia and a burning abdominal pain.

Diagnosis is made most commonly by endoscopy, which also allows a biopsy of the ulcer to be taken to exclude malignancy.

About one-third of duodenal ulcers heal by themselves within a month. Treatment involves a combination of drugs such as antibiotics (known as triple therapy) to eradicate the helicobacter pylori infection. Drugs which reduce stomach acid by inhibiting the cells which produce gastric acid are also used. Dietary advice is to avoid foods which cause indigestion.

Occasionally, emergency surgery may be required if an ulcer causes complications, such as bleeding or perforation of the wall of the stomach or duodenum.

Applicants with a history of a peptic ulcer can usually expect standard rates. However, in severe cases where there is a history of perforation or bleeding a small loading of +50% may be applied.