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Pharmacy teams will encounter patients with GI complaints on a frequent basis and, while most cases can be treated with OTC medication, it is important to be alert for alarm symptoms and be ready to answer any burning questions they may have.
In depth: heartburn
Mrs Clare Evans, a woman in her early 50s, tells you she has “indigestion”. On questioning, she explains that she sometimes gets a burning sensation in the stomach passing upwards behind the breastbone. This is occasionally accompanied by burning in the throat with a bitter taste as if food has been brought back up. She has no other symptoms. The burning most often comes on when she is in bed at night.
Mrs Evans tells you she has put on about 5kg in weight over the past six months. She has had these indigestion symptoms occasionally in the past, always when she puts weight on. She has had the current bout of symptoms for about 10 days but not every night. She has not yet tried to treat her symptoms and is taking no medication from the GP.
Which GI condition?
Indigestion is often self-diagnosed by patients, who tend to use the term to describe pain in the upper to lower abdomen or in the chest.
Patients will use a variety of terms such as indigestion, heartburn, dyspepsia, bloating, nausea and vomiting, and sometimes acid reflux to describe upper GI symptoms. It is vital to establish whether Mrs Evans’ self-diagnosis of indigestion is correct and also to exclude the possibility of serious disease.
The symptoms she describes are most likely to be heartburn (known formally as gastro-oesophageal reflux disease or GORD). When determining whether someone is suffering from heartburn, it is important to find out what is aggravating the symptoms.
Mrs Evans has recently put on weight and says weight gain often causes these symptoms. Heartburn can also be brought on by bending or lying down. In addition, it can be triggered by large meals, while alcohol, smoking and stress can all be causative factors. Reflux symptoms occur more commonly in people aged over 50 years.
As many as half of women suffer from heartburn during pregnancy, which is caused by an increase in intra-abdominal pressure and relaxation of the lower oesophageal sphincter.
Approaching the problem
Mrs Evans is not taking any regular medication and has not tried anything for her current symptoms.
Several medicines are associated with heartburn, the main examples being anticholinergic drugs (particularly those with pronounced anticholinergic effects such as amitriptyline), calcium channel blockers, nitrates and theophylline. The phosphodiesterase inhibitors used to treat erectile dysfunction, such as sildenafil and tadalafil, can result in reflux symptoms in men.
All these types of medicines cause the oesophageal sphincter to relax so it is less able to stop the acid contents of the stomach regurgitating into the oesophagus when the stomach contracts. While the lining of the stomach is resistant to the effects of acid, the oesophageal lining is not. Caffeine in coffee, tea and soft drinks such as cola, and in some analgesics and cold remedies, also relaxes the lower oesophageal sphincter and is commonly associated with heartburn.
Non-steroidal anti-inflammatory drugs (NSAIDs), aspirin or oral corticosteroids (e.g. prednisolone) can aggravate oesophagitis. Bisphosphonates can cause severe oesophagitis. It is important to take plenty of water and stay upright after taking these medicines.
Asking about the symptoms in detail is important. Sometimes the pain can come on suddenly and severely, and radiate to the back and arms. This can mimic a heart attack and urgent medical referral is essential. However, some patients admitted to hospital apparently with a heart attack are found to have oesophagitis instead.
Mrs Evans says she suffers burning in the throat with an acid taste. This is likely to be acid regurgitation, which is commonly associated with oesophagitis. Oesophagitis related to acid reflux can sometimes cause swallowing discomfort, especially when it occurs while swallowing hot drinks or liquids like fruit juice or alcohol.
These symptoms should be distinguished from difficulty in swallowing or dysphagia, which is a sensation of food or liquids sticking in the oesophagus or which do not seem to pass directly into the stomach.
Dysphagia, which may be due to obstruction of the oesophagus, for example by a tumour or a less serious condition such as oesophageal stricture, requires immediate referral. A stricture is caused by long-standing acid reflux with oesophagitis.
Mrs Evans has many of the classic symptoms of heartburn: pain in the stomach, behind the breastbone and in the throat, and also reflux. The symptoms are worse at night after going to bed and when bending over, as is common with heartburn. She has been experiencing symptoms for about two weeks and is not taking any medication. It would be reasonable to advise taking an alginate/antacid one hour after meals.
Antacids can be effective in controlling the symptoms of heartburn and reflux particularly in combination with an alginate. Alginates form a raft that sits on the surface of the stomach contents and prevents reflux. Some alginate-based products contain sodium bicarbonate which, in addition to its antacid action, causes the release of carbon dioxide in the stomach, enabling the raft to float on top of the stomach contents.
Alginate products with low sodium are useful for patients on a sodium-restricted diet (e.g. those with heart failure or kidney or liver problems). Preparations high in sodium should also be avoided during pregnancy.
Mrs Evans should also be advised to take a proton pump inhibitor (esomeprazole, omeprazole and pantoprazole). A PPI can be used for the relief of heartburn symptoms associated with reflux in adults.
PPIs are considered to be among the most effective medicines for the relief of heartburn. They may take a day or so to work fully and if Mrs Evans has continuing symptoms, she should be advised to take an antacid during the 24-hour period.
PPIs work by suppressing gastric acid secretion by blocking the hydrogen-potassium ATPase enzyme (the proton pump) in the cells of the stomach wall. A single dose can last for up to 24 hours or more. Omeprazole is licensed OTC as 10mg tablets (daily dose 20mg), while esomeprazole and pantoprazole are licensed as 20mg tablets (daily dose of 20mg in both cases).
All PPIs should be swallowed whole with plenty of water before a meal. The tablets must not be crushed or chewed. If Mrs Evans gains no relief from a PPI within two weeks, she should be referred to her GP. PPIs should not be taken during pregnancy or when breast feeding. In rare cases PPIs may cause drowsiness.
Lifestyle advice should be given appropriate to the patient. Mrs Evans should be advised to try to lose weight, eat frequent small meals, avoid fatty meals and not to eat three to four hours before bedtime.
It is also important to take care with caffeine and chocolate. She should raise the head of the bed (rather than using extra pillows), steer clear of tight belts and waistbands, avoid bending over, and take time to relax.
Upper GI symptoms: GP referral
Assess symptoms very carefully: age of the patient, symptom severity, area of the GI tract affected, symptom trigger factors, influence of food, medications already taken, medications tried for the GI symptoms, and diet and lifestyle factors such as smoking and alcohol.
Look out for alarm or red flag symptoms (that could indicate cancer). If the patient has:
- Recurring heartburn or indigestion and is 55 years or over
- Concerns about a lump or mass in the stomach
- Unintended or unexplained weight loss
- A cough or loss of voice
- Difficulty swallowing
- Persistent or recurrent nausea or vomiting
- Blood in the vomit or stools
- Persistent abdominal pain, particularly if severe or unrelated to a meal
- A feeling of fullness, which occurs very quickly, or is very tired
- No response to PPIs
- Pain across the back or radiating down the arms (which could indicate angina or a heart attack)
- Symptoms related to prescribed medication (e.g. alpha-blockers, anticholinergics, beta-blockers, bisphosphonates, calcium channel antagonists, corticosteroids, nitrates, NSAIDs, theophyllines, tricyclic antidepressants)
- Tried OTC medication and lifestyle changes, but symptoms still persist.
Indigestion
Mr Angus Peel is 72 years old and complains of indigestion and an upset stomach. He says he has had pain “on and off” in the middle of his abdomen for a couple of weeks. The pain does not seem to be related to food except that occasionally it worsens when the stomach is empty.
You ask about medication and Mr Peel tells you he is taking tablets for his heart, blood pressure and naproxen 250mg twice daily for a painful knee.
On closer questioning you discover that he often takes the NSAID on an empty stomach when he gets up in the morning and in the late afternoon. Mr Peel says he has not taken any medication for his indigestion symptoms.
It sounds as if he is suffering GI symptoms as a result of his taking a NSAID, particularly on an empty stomach. Mr Peel could be advised to try taking the naproxen with food but as he is older it is probably better if you refer him back to the doctor.
GI symptoms from a NSAID are more common in older people and potentially more serious. Older people prescribed a NSAID should also be prescribed a PPI but this does not appear to have happened in this case.
Another consideration given Mr Peel’s heart health is the cardiovascular risk of a NSAID although the risk with naproxen is lower than with others. Mr Peel should be prescribed a PPI and advised to take paracetamol for his painful knee.
Ulcer
Ms Jane Knott, aged 59 years, describes a pain in the upper abdomen to the right of the mid-line. Pain in this region needs careful assessment as it can be difficult to distinguish between an ulcer, gallstones or irritable bowel syndrome (although pain associated with IBS is usually situated in the lower abdomen).
Atypical angina may cause pain in the upper abdomen, while typical anginal pain may be felt as a tight constricting band across the middle of the chest, sometimes with radiation to the neck or arms.
In the case of Ms Knott, the pain in the upper abdomen is gnawing and occurs when her stomach is empty, particularly at night. She says it is relieved by food in general, although aggravated by fatty food, and she takes an antacid. You ask her to point to the pain, which she does. She has no other symptoms and takes no medication apart from the antacid.
This sounds as if it might be a duodenal rather than a gastric ulcer, although they are often difficult to differentiate, partly due to the reducing prevalence of ulcers and the use of PPIs.
The pain of a gastric ulcer is in the same area of the abdomen but is less localised. Symptoms of a gastric ulcer are often persistent and severe, frequently aggravated by food and may be associated with nausea and vomiting. Appetite is often reduced.
Mrs Knott should be referred to the GP. Both types of ulcers are associated with H. pylori infection and she should be tested for this as well as a diagnosis made. Gastric ulcer has an associated risk of cancer.
What about gallstones?
Gallstones can cause severe pain in the upper abdomen and below the right rib margin. Single or multiple stones can form in the gall bladder, which periodically squirts bile through the bile duct into the duodenum to help the digestion of food especially fat.
Stones can become temporarily stuck in the opening to the bile duct as the gall bladder contracts. This causes severe episodic pain in the right upper abdomen below the rib margin, which can be brought on by fat consumption. These pains can be confused with a duodenal ulcer. Any pharmacy customer with these symptoms should be referred.
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Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.