8 Min In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.
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Record learning outcomes
Learning objectives
After reading this feature, you should be able to:
- Advise customers on the most effective way to treat upper GI problems
- Recognise potential complications
- Suggest appropriate lifestyle changes.
Introduction
Around 40 per cent of adults experience dyspepsia and heartburn from time to time, so many people will be coming into pharmacies looking to self-select OTC treatments — but are they using the most suitable product for their symptoms?
This seems unlikely since it is estimated that nearly two-thirds of heartburn sufferers are dissatisfied with their current treatment. So what are the different symptoms to be treated and what should pharmacy teams be looking out for?
For dyspepsia the main symptom is a feeling of pain or discomfort in the chest or stomach that sometimes occurs after eating or drinking. Other symptoms include feeling bloated, burping, or feeling or being sick.
Dyspepsia may be caused by a peptic ulcer or gastro-oesophageal reflux disease (GORD). However, in around six out of 10 people with the condition, their symptoms don’t have a specific cause (functional dyspepsia) since the problem is with how the digestive system is working rather than anything that can be seen and diagnosed with an endoscopy. This used to be called ‘non-ulcer dyspepsia’.
When discussing dyspepsia with a customer, it is important to ask about:
- Symptoms – and whether they have any red flags
- How long they have had these symptoms and how often they occur. Dyspepsia or heartburn that occurs at least twice a week or more for at least four weeks is considered to be frequent
- Their lifestyle, eating habits and any stress, anxiety or depression, to assess for risk factors
- Any medicines they are taking which may cause or exacerbate dyspepsia (e.g. NSAIDs)
- Whether they have already tried any dyspepsia or heartburn treatments.
Helicobacter pylori infection
Severe ongoing indigestion may be caused by a H. pylori infection. According to the Guts UK charity, around 40 per cent of people have H. pylori bacteria in their stomach, but only about one in 10 will experience any symptoms.
“Usually, I ask patients to provide a stool sample to test for H. pylori,” says Dr Luke Pratsides, an East London GP. “The bacteria can cause indigestion-type symptoms and belching and, if left over many years, can lead to a stomach ulcer or in the worst cases, stomach cancer. It is easy to treat with antibiotics.”
Acid reflux
Acid reflux occurs when some of the acidic stomach contents come back up the oesophagus towards the mouth, often caused by relaxation of the lower oesophageal sphincter muscle or increased pressure at the bottom of the oesophagus. Many people don’t realise they have acid reflux as they don’t experience any symptoms, but it can cause the burning sensation, pain or discomfort in the chest and throat that is heartburn.
Acid reflux is most likely to occur after eating, lying down or bending over. Other symptoms include an unpleasant taste in the mouth and swallowing problems. Gastro-oesophageal reflux disease (GORD) is when heartburn and reflux are dominant symptoms. GORD may cause hoarseness, frequent throat clearing, cough, wheezing, asthma and even dental erosion.
Certain medicines (e.g. anticholinergics and benzodiazepines) can decrease lower oesophageal sphincter pressure, causing GORD, but many cases are due to lifestyle factors. “The main triggers of GORD are caffeine, alcohol, smoking, spicy or oily food and eating less than two hours before going to bed,” says Dr Pratsides. “Cutting down or stopping these will help reduce symptoms of GORD in the majority of people.”
GORD may also be more common in pregnant women (because the growing baby pushes upwards on the stomach) and people who are very overweight.
“In the last 30 years, the prevalence of adult obesity has risen from 15 per cent in 1993 to 28 per cent in 2019, and in England in 2018 the majority of adults (63 per cent) were either overweight or obese,” says Devika Dileepkumar, marketing executive for Nexium Control at GSK.
“Living with excess weight puts people at greater risk of heartburn on account of additional weight carried on the waist, negatively impacting the usual functions of the stomach.”
Diagnosing and managing EoS
Eosinophilic oesophagitis (EoE) is an immune-mediated disease of the upper gut or oesophagus that is usually caused by food allergies or other environmental triggers. It results in inflammation of the oesophageal lining, which, if left untreated, can lead to difficulties with swallowing food.
The diagnosis involves taking six biopsies from at least two sites in the oesophagus to specifically count the number of eosinophil white blood cells.
This easily treatable condition is believed to affect around 23,500 people in the UK, but due to the lack of clinical awareness it takes on average up to eight years to be diagnosed, causing significant discomfort, anxiety and embarrassment in the meantime.
Sufferers will typically have a history of ‘slow eating’, drinking lots of water while eating, and avoiding tough, chewy or starchy foods such as meat, rice and bread. They are often labelled ‘fussy eaters’ and may avoid social eating occasions for fear of choking, coughing or retching in public.
New guidelines on the diagnosis and management of EoS were published in May 2022 and in the same month the charity EOS Network launched its ‘Think EoE’ awareness campaign, to increase wider understanding of the disease and recognition of its symptoms.
Potential complications
For most people, heartburn and dyspepsia are a nuisance rather than anything more serious but prolonged acid reflux can sometimes cause severe irritation, inflammation, bleeding and ulceration of the oesophagus (oesophagitis).
Long-term reflux can also lead to Barrett’s oesophagus, in which changes occur to the cells lining the lower part of the oesophagus. Although these altered cells aren’t cancerous, there is a small risk that they will become so over time.
Symptoms of reflux that wake someone at night are a particular risk factor for Barrett’s oesophagus, says Julie Thompson, information manager at the Guts UK charity. “It can be challenging to distinguish between Barrett’s oesophagus and reflux on symptoms alone.”
“NICE guidelines suggest referring someone for endoscopy to check for Barrett’s oesophagus if they show the following risk factors: GORD, long duration of symptoms, increased frequency of symptoms, a previous diagnosis of oesophagitis, hiatus hernia, oesophageal ulcers or oesophageal strictures, and other risk factors such as older age, male sex, family history, obesity, smoking and a hiatus hernia.”
Lifestyle approaches
NICE guidance recommends offering patients simple lifestyle advice as the first-line manage-ment for heartburn and indigestion symptoms. “Lifestyle interventions include stopping smoking with stop smoking services if needed,” says Julie Thompson, “reducing alcohol intake to within healthy guidelines and weight management if the person’s weight is unhealthy. In respect to particular dietary aspects, reduce caffeine intake, fizzy drinks and rich meals high in fat.”
Stress and anxiety can be a cause of functional dyspepsia, so psychological therapies such as cognitive behavioural therapy (CBT) or psychotherapy may be helpful. Medicines that may cause or worsen symptoms include aspirin, benzodiazepines, beta-blockers, bisphosphonates, calcium-channel blockers, corticosteroids, NSAIDs and tricyclic antidepressants.
Other self-management tips include:
- Avoid any specific food and drink triggers, such as acidic foods (citrus- and tomato-based products), onions, garlic and peppermint
- Eat smaller meals
- Avoid eating the main meal within three hours or drinking two hours before bedtime
- Raise the head end of the bed by 10-20 cm, if possible
- Lie on the left-hand side to help reduce night-time reflux episodes
- Don’t use additional pillows, as this may put more pressure on their abdomen and worsen symptoms
- Avoid wearing tight clothing (including tight belts)
- Avoid bending over frequently.
Customers can be directed to the Guts UK website for more information.
“People on long-term treatment for uninvestigated dyspepsia should be offered an annual review”
Medical management
If lifestyle interventions aren’t working for indigestion and heartburn, NICE guidance recommends self-treatment with an antacid and/or alginate but these are only suitable for short-term use. NICE advises that, if these aren’t effective, patients can be offered a proton pump inhibitor (PPI), such as omeprazole, to help reduce the production of stomach acid. Once-daily PPI tablets can be sold over the counter for up to 14 days’ use.
A GP may initially prescribe a four-week PPI course to see if the symptoms improve, or test for H. pylori. An H. pylori infection is treated with PPIs and a combination of antibiotics. “It should be noted that the NICE guidelines recommend leaving a ‘two-week washout period after proton pump inhibitor (PPI) use before testing for Helicobacter pylori with a breath test or a stool antigen test’,” says Julie Thompson.
People on long-term treatment for uninvestigated dyspepsia should be offered an annual review. They should also be advised to reduce their use of prescribed medicines stepwise by using the lowest effective dose ‘as needed’, and by returning to self-treatment with antacids and/or alginates (unless there is an underlying reason why PPIs should be continued).
If patients are diagnosed with GORD following an endoscopy, their GP may prescribe a PPI for four or eight weeks. If this fails to help the symptoms, patients may be prescribed an H2-receptor antagonist.
If someone has proven severe oesophagitis, they should be prescribed a full-dose PPI for eight weeks to aid healing and a full-dose PPI in the long-term as maintenance therapy. It is important they speak to their GP if symptoms persist or return, or if they develop any new symptoms, in which case they may need to be referred to a gastroenterologist or upper gastrointestinal surgeon.
“The public may be unaware that the medication they are buying is masking symptoms and not solving any underlying problem”
Red flags
There are concerns among some healthcare professionals that many people with indigestion and heartburn symptoms are self-medicating with OTC medicines for long periods and that complications and underlying conditions aren’t being diagnosed.
“In some people, heartburn can be a warning for more serious underlying damage to the oesophagus, and early diagnosis makes all the difference to stop cancer in its tracks,” says Professor Rebecca Fitzgerald, director of the Early Cancer Institute and trustee of the Heartburn Cancer UK (HCUK) charity.
According to HCUK’s website (heartburncanceruk.org), 10 per cent of people suffer with heartburn every week. Half a million people in the UK have undiagnosed Barrett’s oesophagus, and 50,000 of these may go on to develop oesophageal cancer. Around 8,000 people die of oesophageal cancer each year.
“The public may be unaware that the medication they are buying is masking symptoms and not solving any underlying problem,” says Mimi McCord, chair of Heartburn Cancer UK. “We recommend that the public should consult with their GP if they have persistent heartburn three or four times a week for three weeks or more. There are tests available to spot any warning signs and treatment is very effective for early disease.”
Customers aged 55 years and over who are experiencing heartburn and indigestion for the first time should be referred to their GP, as they may require an endoscopy to check for any underlying causes.
In some areas of the UK, patients can have a new test for Barrett’s oesophagus called the Cytosponge. This involves swallowing a small capsule containing a sponge that is attached to a piece of string. After a few minutes, the capsule dissolves in the stomach and the sponge is released. The nurse then pulls on the piece of thread. On its way back up the oesophagus, the sponge collects oesophageal cell samples that can then be analysed in a laboratory.
Dr Pratsides says that other red flag signs include unintentional weight loss, difficulty swallowing with food or water getting stuck in the throat, vomiting blood, severe abdominal pain or dark blood in the stools. “If I was concerned about a bleeding ulcer, I would arrange for the patient to be seen immediately in A&E,” he says. “If I was concerned about cancer, I would refer them to a cancer pathway to be seen urgently in hospital outpatients. On this pathway, patients are usually seen within two weeks.”
Managing constipation in adults
Constipation can affect anyone but is more common in women, older people and during pregnancy. According to the NHS website, stomach ache or back pain in adults are not usually symptoms of dyspepsia, but may instead be a sign of constipation.
Since everyone has different bowel habits, there is no definitive definition of constipation, but the term is usually used to describe infrequent stools, difficulty passing stools or the sensation of incomplete emptying.
Constipation has many different causes, including a low-fibre diet, difficulty in accessing a toilet, lack of exercise, anxiety and/or depression. Short-term constipation can be managed in a pharmacy setting.
Chronic constipation is defined as symptoms occurring for at least three months. It isn’t usually life-threatening but can affect quality of life if it remains untreated. It is important to check for underlying causes, which may include certain medicines, diabetes, hypothyroidism, inflammatory bowel disease, irritable bowel syndrome, bowel cancer and neurological conditions.
Test your team
What does your pharmacy team know about the management of constipation?
1. What should be the first step in managing short-term constipation?
INCORRECT.
CORRECT.
INCORRECT.
INCORRECT.
2. Which of these should be used as the first-line laxative?
CORRECT.
INCORRECT.
INCORRECT.
INCORRECT.
3. Which laxative should be used if bulk-forming laxatives fail to work?
INCORRECT.
CORRECT.
INCORRECT.
INCORRECT.
4. Which of these medicines may cause constipation?
INCORRECT.
INCORRECT.
INCORRECT.
CORRECT.
5. Adults should, ideally, consume how much fibre each day?
INCORRECT.
INCORRECT.
CORRECT.
INCORRECT.
6. If a customer has opioid-induced constipation, they should NOT take:
INCORRECT.
CORRECT.
INCORRECT.
INCORRECT.
7. Arachis oil enemas should NOT be used in people with:
INCORRECT.
CORRECT.
INCORRECT.
INCORRECT.
Sources
Clinical
In Clinical
Let’s get clinical. Follow the links below to find out more about the latest clinical insight in community pharmacy.