In November 2020, the NHS launched a new phase of its ‘Help Us, Help You’ campaign encouraging people who have been suffering from diarrhoea, bloating or discomfort in their tummy area for three weeks or more to speak to their GP. Many people don’t discuss bowel symptoms with healthcare professionals, often due to embarrassment or because they assume these are just signs of getting older. But while these symptoms may be caused by common bowel problems, they can also have more serious causes.
Pharmacy teams can help to distinguish between common bowel problems, recommend suitable treatments, offer self care advice and refer customers to their GP as appropriate.
Irritable bowel syndrome (IBS) is thought to affect around one in every five people in the UK, yet it is poorly understood. “IBS is a common disorder of the gut-brain interaction, leading to abdominal pain, bloating, diarrhoea and/or constipation,” says Alison Reid, chief executive of the charity The IBS Network. “There’s no specific cause and no single effective treatment.”
Customers experiencing IBS-type symptoms for the first time should speak to their GP, to rule out other conditions such as inflammatory bowel disease (IBD). “IBD is often associated with a family history and is a more systemic illness, with symptoms such as night sweats, joint pain and weight loss,” explains Alastair Windsor, consultant colorectal surgeon at The Princess Grace Hospital, part of HCA Healthcare UK. “IBS is often associated with abdominal pain and bloating. The abdominal pain is typically linked to bowel activity called the Rome criteria. Appropriate investigation, such as faecal calprotectin, is usually required to distinguish the two.”
Once diagnosed, pharmacy customers can often manage IBS symptoms with the help of their GP and the pharmacy team. “Many people with IBS find that making lifestyle and dietary changes has a positive impact,” says Alison. “Encourage them to keep a 12-week wellness diary, available from The IBS Network, where they record food, mood and events that are happening in their life.”
Alison also suggests limiting caffeine and alcohol, drinking plenty of fluids but not fizzy drinks, eating regular meals and avoiding high-fat foods. Changes to fibre intake will depend on whether customers have constipation – where they should increase soluble fibre such as oats and linseed – or diarrhoea and/or bloating, in which case they should reduce insoluble fibre such as wholemeal and wholegrains.
There’s no specific cause of IBS and no single effective treatment
If lifestyle changes aren’t working sufficiently, pharmacy customers can try over-the-counter (OTC) IBS medicines, such as antispasmodics for any pain and peppermint oil or specific products for diarrhoea, bloating or constipation. They should also consider speaking to a dietitian. The low FODMAP diet involves avoiding foods that aren’t easily broken down in the gut, including some fruits and vegetables, milk and wheat products.
“NICE quality standards state that if first-line diet treatment isn’t effective, the patient should be referred to a state-registered dietitian to assess their suitability for an elimination diet, for example, low FODMAP,” says Julie Thompson, information manager at the charity Guts UK. “Unfortunately, the FODMAP diet isn’t suitable for everyone; it can be harmful for people who have, or have had, eating disorders in the past, for example. Plus, it can be very restrictive and challenging to do without help.”
Alison suggests the inclusion of probiotics in the diet as well. “Clinical studies have shown that some probiotics containing certain specific strains of bacteria may help to reduce some symptoms of IBS, particularly bloating and diarrhoea, in some patients,” she says. “NICE guidelines for IBS suggest that probiotics be trialled for at least a month to ensure the best results. The IBS Network’s experts also recommend that if one probiotic isn’t effective, it’s worth trying a couple more brands. If someone has tried up to three different probiotics and these are giving little relief from their symptoms, then it’s unlikely that any other probiotic will help.”
Stress and anxiety may also trigger flare-ups of IBS. “Encourage the customer to identify any associated stress, anxiety, and/or depression, and to manage appropriately, such as with cognitive behavioural therapy (CBT) and hypnotherapy,” Alison advises.
Crohn’s disease and ulcerative colitis – the two most common inflammatory bowel diseases (IBD) – affect around 500,000 people in the UK. According to the charity Crohn’s & Colitis UK, these auto-immune diseases can start at any age, but usually before the age of 30. Crohn’s disease causes ulcers and inflammation anywhere in the gut, from the mouth to the anus, whereas ulcerative colitis affects only the large bowel. Both diseases can cause fluctuating symptoms including cramping pains; frequent and urgent diarrhoea, sometimes with blood and thick mucus; swollen joints; mouth ulcers; tiredness; and anaemia.
Some people with IBD find that lifestyle changes (e.g. avoiding certain foods) improve their symptoms, but they should speak to their doctor first. “Food can make symptoms worse, but this is very individual and is dependent on the severity of symptoms and the stage of disease,” says Julie. “It’s complicated, which is why a specialist gastroenterology dietitian is required to give advice. Smoking can make Crohn’s disease worse, but ulcerative colitis is less common in people who smoke, and flares are fewer. However, smoking is generally bad for general health, so patients are advised to stop. Anyone who has ulcerative colitis who is considering stopping smoking should notify their IBD team who will review their situation.”
Most people with IBD need to take prescribed medicines to reduce gut inflammation or dampen down the immune system. If medicines aren’t working well enough, they may need surgery to remove the damaged part of the bowel. Crohn’s flare-ups may improve with a liquid diet called enteral or parenteral nutrition.
“Many patients are keen to avoid medication if possible,” says Alastair. “There are certain clinical situations where dietary changes, including liquid diets, are very effective treatments in IBD. The key issue, however, is ongoing inflammation. If patients feel better, but have underlying inflammation in the background, the long-term complications of both Crohn’s and Colitis can still occur.”
IBD can affect the absorption of nutrients, increasing the risk of long-term conditions such as osteoporosis. But customers should speak to their doctor before taking any supplements. “A common deficiency is vitamin D, which everyone should be taking during the winter months in the UK anyway,” Julie explains. “People with IBD also have a higher calcium requirement than the general population – 1000mg/day compared with 700mg. However, an assessment is needed to check whether someone is getting enough from their diet. Some micronutrient supplements, such as iron, can make IBD symptoms worse.”
One in 100 people in the UK has coeliac disease, but only 30 per cent of people with this autoimmune condition have been diagnosed. In people with coeliac disease, the immune system damages the lining of the small bowel when they eat gluten, which is found in wheat, barley and rye. This causes a range of symptoms, including altered bowel habits such as diarrhoea, constipation or both; bloating; nausea; weight loss; tiredness; mouth ulcers; and anaemia. Some people also have an itchy raised red rash called dermatitis herpetiformis and/or neurological symptoms such as numbness and tingling.
Coeliac disease can be confused with IBS, or some people may put the symptoms down to stress. Pharmacy customers with suspected IBS should be tested for coeliac disease before IBS is diagnosed. The diagnosis of coeliac disease in adults is usually a two-step process: a blood test to look for antibodies, followed by an endoscopy with biopsy to look for damage to the intestine. In July 2020, interim guidance from the British Society of Gastroenterology stated that some adults with suspected coeliac disease can now be diagnosed based on blood test results alone, cutting out the long wait for an endoscopy with biopsy.
There’s no cure and no medication for coeliac disease, so the only treatment is a strict gluten-free diet for life. Information is available from various charities, such as Coeliac UK, as well as the NHS, but patients should also be referred to a dietitian. They may be advised to take some vitamin and mineral supplements as coeliac disease, like IBD, can affect the absorption of key nutrients, such as iron and B vitamins and trigger lactose intolerance.
Coeliac disease can be confused with IBS, or some people may put the symptoms down to stress
Haemorrhoids, also known as piles, are swollen blood vessels in and around the anus. Symptoms include bright red blood after pooing, an itchy anus, lumps in the anus and slimy mucus in underwear or on toilet paper. They are more common in people who are constipated or very overweight, pregnant women and people who do heavy lifting.
“Many people are unaware they have haemorrhoids as these are invisible and asymptomatic,” says Dr Deborah Lee, GP at Dr Fox Online Pharmacy. “However, from time to time, symptoms can flare-up. The most common symptom is rectal bleeding. This tends to occur when a patient is sitting on the toilet and trying to open their bowels. Often, bleeding is painless or only associated with mild discomfort.”
Customers with any new rectal bleeding over the past two to three weeks should be referred to their GP. “Never assume rectal bleeding is due to haemorrhoids,” says Dr Lee. “Most rectal bleeding is not due to bowel cancer, but the diagnosis needs to be excluded.”
If customers have been diagnosed with haemorrhoids, OTC topical treatments may help to ease any pain. “Some treatments contain steroids, which have potent anti-inflammatory action and help to relieve pain and reduce swelling,” says Dr Lee. “Some also contain a local anaesthetic. These are available as creams, ointments, suppositories, spray or foam. All have a similar degree of efficacy and it’s a matter of personal choice for the patient. Advise patients to soak in a hot bath for 10 minutes, then apply a cream or ointment to the area, or insert a suppository. Avoid using scented bath products as this can aggravate any skin irritation – use plain hot water.”
To manage and prevent haemorrhoids, it’s important to treat any underlying constipation with lifestyle changes, such as eating more fibre, drinking more fluids and taking regular exercise. “Symptoms can be reduced by using laxatives,” Dr Lee explains. “However, laxatives should only be used in the short term and with care and caution.”
If symptoms do not improve after seven days, customers should be referred to their GP, who may prescribe stronger medicines or recommend hospital treatments to shrink the haemorrhoids.
Most rectal bleeding is not due to bowel cancer, but the diagnosis needs to be excluded
One in 15 men and one in 18 women will be diagnosed with bowel cancer during their lifetime. More than nine out of every 10 new cases are diagnosed in people over 50 and nearly six out of 10 cases are diagnosed in people aged 70 and over. However, bowel cancer can affect people of any age.
People are more at risk if they have a strong family history of bowel cancer; have a history of non-cancerous growths in their bowel; have inflammatory bowel disease or type 2 diabetes; carry a lot of weight around their waist; or have an unhealthy lifestyle, such as eating a lot of red and/or processed meat and few fibre-rich foods, and doing little exercise.
Bowel cancer is treatable and curable, especially if it is diagnosed early. In England, Wales and Northern Ireland, people over 60 are invited to take part in the national bowel cancer screening programme every two years until they reach the age of 70. In Scotland, screening starts from the age of 50. However, screening programmes have been delayed due to the Covid-19 pandemic, making it even more important that anyone with possible symptoms of bowel cancer seeks medical advice.
In November 2020, Bowel Cancer UK expressed concern that bowel cancer cases were being missed, as the number of people in England waiting for diagnostic tests had increased almost tenfold compared to the average monthly figure the previous year. More than 59,000 people who needed investigations for suspected bowel cancer symptoms waited more than six weeks for a colonoscopy or flexible sigmoidoscopy in September 2020.
NHS England and Public Health England (PHE) are encouraging more people to speak to their GP about their bowel symptoms. “We can’t say this strongly enough; if you have any symptoms of bowel cancer, please don’t put off visiting your GP,” says Genevieve Edwards, chief executive at Bowel Cancer UK. “Bowel cancer is the UK’s second biggest cancer killer, but it doesn’t have to be, as it’s treatable and curable, especially if it’s diagnosed early. So, it’s really important that anybody with signs of the disease, including bleeding from the bottom and/or blood in the poo, a persistent and unexplained change in bowel habit, unexplained weight loss, extreme tiredness for no obvious reason and a pain or lump in the tummy, contacts their GP straight away.”
For more information about the ‘Help Us, Help You – Accessing NHS Services Cancer’ campaign, see the PHE campaign resource centre.