Digestive disorders can vary from occasional discomfort to ongoing agony. We look into the most common digestive complaints and why no one need suffer in silence

Indigestion and heartburn

“The most common digestive complaints at this time of year are heartburn and indigestion – terms that are often used interchangeably,” says Dr Anton Emmanuel, gastroenterologist at University College Hospital in London. “At Christmas, we become more sensitive to pain as we eat more rich food, and more food in general. We then lie in front of the TV and it exposes the oesophagus to more acid.”

Indigestion occurs when stomach acid comes into contact with the sensitive, protective lining of the digestive system. Gastro-oesophageal reflux disease (GORD) is one of the most common causes of recurrent indigestion and occurs when continuous reflux causes inflammation of the oesophageal lining. This type of inflammation is also known as oesophagitis.

Around one in five people experience at least one episode of GORD a week, while one in 10 suffer every day, according to NHS Choices. Heartburn is a common symptom of GORD and is “a sense of burning that often becomes more pronounced after food or when lying down,” says Dr Emmanuel.

Heartburn can have various underlying causes, but it occurs when there is a failure of the lower oesophageal sphincter (LOS) – the ring of muscle at the bottom of the oesophagus. This muscle acts like a valve, opening to allow food into the stomach and then closing again to prevent stomach acid leaking up into the oesophagus. In heartburn sufferers, this mechanism is disrupted, which allows acid to leak out of the stomach. Increased pressure inside the abdomen, due to obesity or pregnancy, can also encourage acid reflux. Increased progesterone production during pregnancy can also weaken the LOS, as can chemicals in cigarette smoke and certain medicines (e.g. nitrates, which are prescribed to widen blood vessels).

Symptoms of indigestion are often caused by increased sensitivity in the lining of the stomach or simple stretching of the stomach after overeating. Symptoms tend to come and go and are rarely constant. Pain in the upper abdomen is the primary complaint. However, sufferers may also report:

• Feeling uncomfortably full
• Bloating l Belching
• Food or fluid reflux
• Nausea
• Vomiting

As with all conditions, prevention of indigestion and heartburn is better than cure, so advise customers to follow these self-care tips:

• Loose weight, if necessary
• Avoid rich, spicy or fatty foods and caffeinated drinks
• Limit alcohol consumption
• Quit smoking
• Eat at least three to four hours before lying down
• Avoid tight clothing

If symptoms persist, you can recommend that they raise the head of their bed a few inches, as lying flat increases the risk of stomach acid leaking into the oesophagus.

OTC remedies are also available to help ease heartburn and indigestion symptoms. “Indigestion can either be worse when hungry or after eating,” says Dr Emmanuel. “If it’s worse when hungry then that’s probably due to acid, so taking an OTC remedy can be effective. If it’s worse after eating, that’s probably due to overindulgence.”

Common OTC treatments include antacids, which work by neutralising stomach acid to prevent it from irritating the lining of the stomach. For heartburn and indigestion caused by acid reflux, alginates can be effective. These inhibit acid reflux by forming a foam barrier or “raft” on the surface of the stomach’s contents.

For customers who don’t find relief with antacids or alginates, medicines called proton pump inhibitors or H2-receptor antagonists may be effective. These are usually prescribed by GPs, although some are available OTC. Ask your pharmacist to explain the pros and cons of these medicines if you are not familiar with them.

Constipation

Constipation is a common condition that affects people of all ages. According to NHS Choices, one in seven adults and one in three children will be suffering from constipation at any one time. It is twice as common in women as men, particularly during early pregnancy, when two in five women suffer.

Normal bowel habits vary from person to person, with some people opening their bowels several times a day and others only doing so every three to four days. Constipation is therefore defined as a reduction in the number of times a person normally passes stools. They may also:

• Strain while passing stools
• Feel unable to completely empty their bowels
• Pass hard or lumpy stools
• Experience bloating, nausea or a reduced appetite

Constipation arises when stools remain in the colon for too long, causing too much water to be absorbed back into the body. Why this occurs can be difficult to determine, but causes may include:

• A lack of dietary fibre
• A change in eating habits
• Ignoring the urge to “go”
• Dehydration
• Depression or anxiety
• Side effects of certain medicines (e.g. antidepressants or antacids)

Dr Emmanuel explains: “Constipation is caused when the pelvic muscles in the core are not right. This may be due to eating abnormally, causing the contents of the stomach to become erratic and unpredictable. Changing stress levels can also affect pelvic floor coordination.”

Constipation is also common during pregnancy, when progesterone levels increase. Progesterone acts as a muscle relaxant, which affects bowel muscle contraction and the movement of waste products through the body.

Diet and lifestyle changes should be recommended first. But it can take several weeks for them to have their full benefit and for regular bowel patterns to become established. To maintain bowel health and avoid constipation, customers should:

• Increase their fibre intake. They should aim for 18g per day via wholemeal cereals, oats, nuts, seeds, fruit and vegetables. Fibre can help food to pass through the digestive system, but it should be introduced gradually to avoid bloating
• Add bulking agents (e.g. wheat bran) to their diet
• Exercise for at least 150 minutes a week
• Stay hydrated
• Respond to bowel movements

If lifestyle changes are ineffective, a bulk-forming laxative (e.g. ispaghula husk) or an osmotic laxative (e.g. lactulose) can help the stools to retain fluid, making them softer and easier to pass. These usually take two or three days to have an effect. Alternatively, if the stools are soft but the customer still has difficulty passing them, a stimulant laxative (e.g. senna) will encourage movement in the digestive tract. These usually have an effect within six to 12 hours.

Dr Emmanuel explains: “You need to differentiate between the urge to go and not going, and no urge to go, which requires more liquids, more exercise and perhaps an OTC treatment. The urge to go and not going may require the occasional stimulant.”

Long-term complications of constipation are rare, but can include hemorrhoids, faecal impaction (hard stools collecting in the rectum) and bowel incontinence. Chronic constipation can also be a sign of a serious underlying condition, such as diabetes, inflammatory bowel disease, or colon or rectal cancer.

Fruit and vegetables are a good source of fibre

Diarrhoea

Diarrhoea is the passing of looser or more frequent stools than normal. It affects everyone occasionally. The most common cause is bowel infection, which may be the result of a virus (e.g. norovirus), bacteria (e.g. Campylobacter) or parasite, (e.g. giardiasis). Short-term diarrhoea can also be caused by:

• Anxiety
• Certain medicines (e.g. antibiotics)
• Excessive amounts of coffee or alcohol
• Food allergy
• Overeating rich food

Symptoms and severity vary depending on the cause. Sufferers may simply experience slightly watery stools alongside a brief upset stomach, or they may endure prolonged watery stools with stomach cramps and a frequent, urgent need to use the toilet. Common symptoms also include nausea, vomiting, headaches and appetite loss. Dehydration can occur in severe cases, so advise customers to frequently sip water and eat small, simple meals once they feel able to.

Most adult cases clear up within two to four days, while children may take five to seven days. “Overindulgence should settle within 24 hours,” says Dr Emmanuel. “If there’s persistent diarrhoea that lasts for longer than a few days, blood loss or severe abdominal pain then that may be a sign of a more serious underlying condition.”

Anti-diarrhoeal medication can be used when it’s important to reduce the duration of the illness, such as before a long journey. Loperamide is often recommended, but note that it is unsuitable for children under 12 years. Painkillers can be used to is important that all sufferers stay hydrated. Rehydration salts that are mixed with water can be a useful option.

It’s also important to prevent transmission of an infection. To do so, sufferers should:

• Wash their hands thoroughly after using the toilet and before preparing or eating food
• Clean the toilet thoroughly with disinfectant after each bout of diarrhoea, including the handle and seat
• Avoid sharing personal items, e.g. cutlery
• Avoid contact with others for at least 48 hours after the last bout of diarrhoea

Irritable bowel syndrome

“Irritable bowel syndrome (IBS) is a big umbrella term,” explains Dr Emmanuel. “It is the presence of abdominal pain, an altered bowel function and the temporal relationship between pain and bowel function.”

IBS usually appears for the first time between the ages of 20 and 30 years old, after which symptoms tend to come and go following stressful periods or eating aggravating foods.

Symptoms vary, but most commonly include diarrhoea, constipation or a mix of both. Sufferers may also experience:

• Abdominal pain that may be relieved by passing stools
• A change in bowel habits
• An urgent need to open the bowels
• A feeling that the bowels are not fully emptied after using the toilet
• Abdominal bloating or swelling
• Flatulence
• Mucus in the stools

IBS occurs when food moves incorrectly through the digestive system. If food moves too quickly, diarrhoea can occur as there is not enough time for water to be absorbed from the stools. On the other hand, if it moves too slowly, it may result in constipation because excessive absorption of fluid from the stools makes them hard and difficult to pass. This may be due to:

• Signal disruption between the brain and the gut
• Oversensitivity to digestive nerve signals, so mild indigestion is felt as distressing abdominal pain
• Raised serotonin levels after certain foods or during a stressful period of time, which affects the normal function of the gut

IBS may be an indicator of a serious underlying condition if it is accompanied by unexplained weight loss, anaemia, bleeding from the anus, or abdominal pain or lumps.

However, IBS alone, although painful and debilitating, is not a physical concern. “It’s critical that patients understand that IBS does not develop into a more serious condition,” says Dr Emmanuel. “Once you’ve had a proper diagnosis, it’s very stable. The chance of developing cancer is the same risk as someone who hasn’t got IBS.”

The impact of IBS on mental health is not clear cut. According to NHS Choices, three out of four IBS patients suffer at least one bout of depression, while just over half develop generalised anxiety disorder. Yet Dr Emmanuel says that these statistics are easy to misinterpret. “The prevalence of depression is one in five,” he says, “and one in 10 people have IBS. Therefore, out of 100 people, 10 per cent will have IBS and five per cent will have depression. There’s a high prevalence of mood disorders in IBS patients, but mood disorders are very prevalent anyway.”

The link between IBS and wellbeing is, however, unquestionable, although patient embarrassment means that many people fail to seek a diagnosis. “It’s a very taboo subject. People feel they can’t control their symptoms,” says Dr Emmanuel. “If you’re bloated then you feel you can’t wear certain clothes. People feel they can’t eat in public or become concerned about their toilet habits. This all increases anxiety much more than just the abdominal pain that comes with IBS,” he explains.

Although there is no cure for IBS, diet and lifestyle changes can help to improve symptoms. Dr Emmanuel’s advice for patients is this: “Keep a bowel and food diary to help identify triggers and then you can see a pattern emerging. See what works for you and, more importantly, what doesn’t work.”