Functional Gastrointestinal Disorders and the Military Service Member: What You Need to Know.
An IFFGD Publication by: Mark S. Riddle, MD, DrPH (Captain, US Navy, retired), University of Nevada, Reno School of Medicine and the VA Sierra Nevada Health Care System, Reno, NV
There is an old Civil War saying, “It takes good guts to be a soldier.” While this was most likely an adage that described the grit and bravery required to be a warfighter, it also described the chronic bowel problems the service member faced from poor nutrition and uninhabitable living conditions. However, this adage also applies to the present day where there are a number of common chronic gastrointestinal (GI) disorders which today’s service members may experience. At the top of the list are functional gastrointestinal disorders (FGID) such as irritable bowel syndrome (IBS), functional dyspepsia, functional constipation, and functional abdominal pain syndrome (FAPS). While these disorders occur frequently in the civilian population, there are some unique aspects that can affect the active service member and veteran.
Rate of occurrence
- Functional constipation is the most common diagnosed disorder, followed by IBS, and then dyspepsia.
- Compared to civilians, Functional Gastrointestinal Disorders (FGIDs) are less common in military service members. This may be due to many military service members having an overall healthier lifestyle than civilians, military service members mostly being made up of men (who have lower risk than women), or military service members are less likely to seek care for minor illnesses, thus leading to underreporting of FGIDs.
- Once diagnosed with an FGID, the symptoms may last for several years, or may be a lifelong disease in some military service members.
- Chronic bowel problems after military service have been documented from many military conflicts, including the Civil War, World War I, the first Persian Gulf War, and Operations Enduring Freedom and Iraqi Freedom.
- Similar to civilian populations, risks of FGIDs in military populations are higher in women and those with underlying psychological health issues such as depression or anxiety.
- The most common risk factor in all populations is contracting a bout of acute gastroenteritis, diarrhea or dysentery (bloody diarrhea) caused by an intestinal infection. GI infections are a very frequent occurrence in military service members who deploy to the tropics or sub-tropics (about 30% per month).
- Risk following different types of intestinal infections including viral, bacterial and/or parasitic infections have been described in military studies.
- The more severe and prolonged an acute GI infection, the higher the risk of developing an FGID.
- Both acute and chronic stressful life events have also been found to increase risk of FGID.
- When acute life stressors and GI infection occur at the same time, which may happen during combat deployments, the risk is even higher.
- Because of the association between acute GI infection and risk of an FGID, prevention of infection needs to be prioritized through safe food and water, and improved sanitation and hygiene while on deployment when feasible.
What to do if you experience persistent abdominal symptoms
- If you are having serious stomach or bowel problems of any duration such as bleeding, vomiting, fever, or dehydration you should seek care immediately. In addition, any unintentional weight loss, or waking up in the middle of the night from diarrhea are concerning symptoms for which you should seek care.
- If you are having abdominal pain or changes in bowel habits that are not severe but are lasting more than a month, you should seek care.
- It is important to note, that after a bout of acute gastroenteritis or diarrhea, you can have changes to your normal bowel function, but these generally go away within a couple weeks.
- FGID symptoms after an acute intestinal infection may not begin immediately and may take up to a year to develop.
- IBS has been shown specifically to be triggered by specific bacterial infections including Campylobacter jejuni, non-typhoid salmonella and shigella. These three infections were also recognized in Gulf War and Southwest Asia Veterans.
- It is also important to note that some infections during deployment (or travel) overseas, and those experienced while at home (less common), can be caused by parasites. Parasites are a unique type of infection which can cause prolonged abdominal symptoms. Fortunately, if they are diagnosed by laboratory tests and identified, they can be treated effectively.
- Your healthcare physician will ask you questions about your symptoms, your medical history, and your family history to better understand what is going on and what might be causing your symptoms. Blood tests, stool tests and/or referral to a gastroenterologist may be some of the next steps.
- Less frequent causes of persistent abdominal symptoms in military service members include inflammatory bowel disease and celiac disease.
- Unfortunately, there are no cures for FGID, but there are a number of medications that can help to alleviate and control symptoms. Further, most FGIDs which occur after a gut infection will improve or even completely resolve over months to years with supportive therapy.
Presumption of service connection
- Functional gastrointestinal disorders, including IBS, dyspepsia and functional abdominal pain syndrome are designated by the Department of Veteran Affairs (VA) as one of four Medically Unexplained Illnesses in Gulf War Veterans.
- These FGID illness must have appeared during active duty in the Southwest Asia theater of military operations which includes any time between August 2, 1990 to present. This includes Veterans who served in Operation Iraqi Freedom (2003-2010) and Operation New Dawn (2010-2011).
- The VA presumes certain chronic, unexplained symptoms existing for 6 months or more are related to Gulf War service without regard to cause.
- The presumption of service connection means that Gulf War Veterans who meet these criteria do not need to prove a connection between their military service and illnesses in order to receive VA disability compensation.
- What is less clear is the situation where a service member develops a FGID after a gastrointestinal infection while on a deployment, or in garrison. In this case it would be important to document the cause of the infection.
- If you suspect your FGID is a result of your military service, you should consult with your local Veterans Health Administration benefits counselor during separation or retirement.
Chronic FGIDs are common among service members and veterans and are linked to military specific exposures and acute gastrointestinal infections. More research is needed to understand how military unique exposures and infections can trigger FGIDs. If you are experiencing persistent abdominal symptoms, you should seek care at your military treatment facility to establish the right diagnosis and get started on the best treatment. The VA has determined that FGID in Gulf War Veterans are associated and may qualify for a disability rating. For all patients with FGIDs, better diagnostics and treatments are needed.
Adapted from IFFGD Publication #440 FGIMDs and the Military Service Member by Mark Riddle