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Bowel down

Bowel health issues are a cause of embarrassment for many customers, but pharmacy teams can be there to provide reassurance and advice.

Talking about bowel health can feel a little embarrassing… to say the least.

“We know that it can be hard for people to talk about their bowels,” says Dr Rachel Ainley, head of research at Crohn’s & Colitis UK. “Pharmacy staff can help make it easier by finding a private consulting space to discuss symptoms and offer reassurance that these could be signs of a wide-ranging number of conditions… We need your help to get people an early diagnosis and started on treatment when it can do most good.” 

Interventions from simple conversations in the pharmacy could be vital in spotting something serious. So let’s take a look at some of the most common bowel health concerns…

Common conditions

Irritable bowel syndrome (IBS) affects up to 20 per cent of people in the UK – mainly those aged between 20 and 39. The chronic condition creates problems with the function of the bowel, triggering changes in bowel habit and bloating.

The main causes of IBS can be split into two categories, says Dr Simon Smale, gastroenterologist and chair of the IBS Network. The first, he explains, is known as post infectious IBS, which “people are often left with after an attack of gastroenteritis or a course of strong antibiotics, which can severely deplete the colonic microbiome”. The second is post traumatic IBS, which “many people report starting after an event or series of events that were traumatic or upsetting”. 

According to the National Institute for Health and Care Excellence (NICE), a diagnosis of IBS is likely if any of the following signs (without other red flags) have been present for at least six months: 

  • Tiredness
  • Nausea
  • Back pain
  • Headache
  • Increased urinary frequency
  • Bloating
  • Change in bowel habit

● Abdominal pain and/or discomfort which is either relieved by defecation or associated with a change in bowel frequency or stool form and is accompanied by at least two of these symptoms: altered stool passage, bloating, made worse by eating, and passing mucus.

These symptoms can usually be treated with a combination of dietary changes, lifestyle adjustments and medication.

The first step is to recommend a healthy, balanced diet with plenty of fluids. In particular, adjusting fibre intake can make a significant difference. Those suffering principally from diarrhoea or bloating should reduce their intake of insoluble fibre (e.g., brown rice, bran, wholemeal flour) whilst those with constipation need more soluble fibre (e.g., oats). Customers should also consider reducing their intake of caffeine, alcohol and fizzy, carbonated drinks. 

If simple dietary changes don’t have much effect, referral to a dietician is advisable. They may suggest a trial of a low FODMAP diet. Reducing intake of high fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) foods, such as sugars found in a variety of fruit and vegetables, milk and wheat, can improve symptoms in 75 per cent of people, says the IBS Network, but should only be done under the supervision of a dietician. 

The main medication used to treat IBS includes: 

  • Bulk-forming laxatives to treat constipation. Most laxatives, barring lactulose, can be recommended
  • Linaclotide can be prescribed by GPs for severe constipation
  • Loperamide can be recommended for persistent diarrhoea 
  • Antispasmodics, which include mebeverine hydrochloride, alverine citrate and peppermint oil, can help to relieve abdominal pain
  • A low dose antidepressant can be considered if antispasmodics don’t help.

Crohn’s disease and ulcerative colitis are the two most common forms of inflammatory bowel disease (IBD), affecting over 500,000 people in the UK, usually between the ages 15 and 25. Both conditions have a significant effect on the digestive tract, with colitis triggering inflammation and ulceration on the inner lining of the colon and rectum, while Crohn’s causes the gut wall to become inflamed. 

“Crohn’s and colitis happen when the body’s immune system goes wrong,” says the charity Crohn’s & Colitis UK. “We don’t know why the immune system attacks the body, but it’s probably a mix of genes and the environment.” 

In addition to this, some studies have found that a low intake of fruit and vegetables as well as high consumption of red meat could be factors. 

Symptoms of the two conditions are fairly similar. Those who suffer from Crohn’s disease will experience abdominal pain, diarrhoea, blood in faeces, fatigue, mouth ulcers, loss of appetite, weight loss and anaemia. For colitis, diarrhoea (often with blood or mucus), cramps, loss of appetite, weight loss and anaemia are all common signs. 

“Faecal incontinence or being woken up in the night by the need to defecate are common symptoms of Crohn’s or colitis, but very rare with IBS,” says Dr Marion Sloan, GP and chair of the Primary Care Society of Gastroenterology. “The risk of developing Crohn’s or colitis is three times higher if the patient has a family history, while having other inflammatory conditions, or a history of multiple autoimmune disorders, could also point towards Crohn’s or colitis.”

There is currently no cure for ulcerative colitis or Crohn’s disease, and treatment depends on how severe the symptoms are, and how much of the gut is affected. 

Patients suffering from Crohn’s disease may need to take steroids from time to time. These can help to relieve symptoms by reducing inflammation in the digestive system, but can cause side effects like weight gain, indigestion and sleeping problems. Customers should be advised that steroids can take a few days, even weeks, to start to work, and should not be started or stopped without professional medical advice. 

Aminosalicylates (5-ASAs) are often used to treat those suffering from mild to moderate ulcerative colitis as, like steroids, they help to reduce inflammation and allow damaged tissue to heal. 5-ASAs can be taken orally, as a suppository or through an enema – how they are taken usually depends on the severity of the patient’s condition. Unlike steroids, 5-ASAs rarely have side effects, but customers may experience headaches, stomach pain and a rash. 

Some 20 per cent of people experience constipation regularly, according to the charity Bladder & Bowel UK. While bowel movement frequency varies from person to person, it’s likely to be constipation if an individual has not defecated at least three times in a week, if stools are hard, lumpy and/or dry, or they are straining or in pain. 

“It’s important for people to understand what is their ‘normal’ so they can recognise when they need to seek help,” says Julie Thompson from Guts UK. “Constipation can be caused by lack of fibre, lack of activity or insufficient fluid intake. It could also be the result of medication, especially those containing opioids. It’s also common in people with neurological disease such as Parkinson’s and MS.”

Regular meals and plenty of water every day should make a difference to those suffering from constipation. Increasing fibre intake also helps some people. 

“Aim for a minimum of five portions of fruit and vegetable per day,” says Julie. “Particularly good for constipation are prunes and kiwi. Increase the intake of fibre slowly. Also include wholegrain carbohydrates and drink two litres of fluid a day.” 

Additionally, pharmacy staff can recommend that customers make sure they are regularly exercising to get their digestive system moving. Should symptoms persist, laxatives can be recommended, but these should not be taken frequently. 

Symptoms of diarrhoea include cramping pains, loose stools, headache, vomiting and sometimes fever. Most cases can be treated in the pharmacy. 

“Acute diarrhoea is generally caused by gastroenteritis or food poisoning. This is usually short-lived. Diarrhoea that lasts longer than four weeks should be investigated to identify the cause,” explains Julie. “Some of the common causes of chronic diarrhoea are IBS, food intolerance, inflammatory bowel disease and bowel cancer.” 

Customers should also be referred if they report diarrhoea for 14 days plus, have blood in their faeces, a high fever, severe abdominal pain, are unable to keep fluids down and are dehydrated.

Rehydration is essential because additional fluids are needed to replace those that have been lost. Over the counter oral rehydration sachets can be recommended.

There is no need for sufferers to stop eating, but it might be beneficial to avoid dairy and spicy foods. Small, light meals are best, including carbohydrates to promote fluid and salt absorption. If symptoms persist, anti-diarrhoeals (e.g., loperamide) can be used to shorten an attack.

Good gut health

The gut is home to 100 trillion microbes, which make up the gut microbiome. These microorganisms are important for normal gut function and digestion as well as for supporting the immune system.

“Although there is no definition of what constitutes a healthy gut microbiome, many health conditions have been linked to an altered gut microbiome,” says Dr Linda Thomas, secretary of the British Gastroenterology Gut Microbiota for Health expert panel. “IBS and constipation are common conditions that may be associated with adverse changes in the gut microbiome.”

Studies have shown that probiotics can help to maintain good gut health. It’s important to recommend that customers try a good quality product. “Quality can be assessed by checking the label. The full name of any probiotic strain should be printed, but as well as the species, there should be a code or name that exactly identifies the strain,” says Dr Thomas. She advises that customers should try a probiotic for at least eight weeks as they can take a while to be effective.

Red flags

Bowel cancer

Bowel cancer is the country’s second biggest cancer killer, with 43,000 cases diagnosed in the UK every year. Detecting it at an early stage is vital, as nine in 10 will survive if it’s picked up early. The good news is that more people are being urgently referred for key tests that can diagnose it, which indicates that more are seeking help after noticing changes, according to charity Bowel Cancer UK. 

“At the forefront of healthcare, pharmacy teams are ideally placed to raise awareness of bowel cancer,” says Claire Coughlan, clinical lead at Bowel Cancer UK. “In particular about the symptoms and the NHS screening programme. The advice of pharmacy teams can really help by informing and reminding patients that it is best to get checked out.” 

Symptoms customers need to be alerted to include:

  • Bleeding from the anus and/or in faeces
  • Persistent and unexplained change in bowel habits
  • Unexplained weight loss
  • A pain or lump in the abdominal region
  • Extreme fatigue.

“It’s important to know that most people with these symptoms won’t have bowel cancer. But if a customer has any of these, they should be encouraged to see their GP,” says Claire. 

Risk factors include being over the age of 50, a strong family history, history of polyps, longstanding inflammatory bowel disease (IBD), type 2 diabetes and living an unhealthy lifestyle. “Scientists believe 54 per cent of all bowel cancers could be prevented by having a healthier lifestyle,” explains Claire. “Risk can be reduced by taking some simple steps to improve diet. Avoid processed meat and red meat; eat plenty of fibre; be a healthy body weight.” 

Bowel cancer screening reduces cancer deaths by 25 per cent, says Public Health England (PHE). In England, screening is offered every two years to people aged 60-74, and this is gradually being rolled out over the next four years to people aged 50-59 as well. In Scotland, screening starts from age 50; in Wales, it’s 55-74 and in Northern Ireland, it’s 60-74.

“Make sure that you and your colleagues understand the importance of screening. It can detect bowel cancer early before any symptoms appear, when it is easier to treat,” says Claire. 

Pancreatic cancer

Pancreatic cancer has the lowest five-year survival rate of all of the 22 most common cancers in the UK, at 7.3 per cent. Whilst this number is low, it has improved steadily over the last few years and Pancreatic Cancer Action (PCA) is aiming to raise it to 13 per cent by 2030.

As with most cancers, early diagnosis is key, with survival odds increasing by 30 per cent. Currently, 43 per cent of all cases are diagnosed in A&E, when the cancer is more likely to be at a later stage.

Symptoms customers need to be aware of include:

  • Indigestion that doesn’t respond to treatment
  • New onset type 2 diabetes in patients of normal or under weight
  • Mid-back pain
  • New onset of IBS-like symptoms in people over the age of 45
  • Jaundice
  • Change in bowel habits
  • Unexplained weight loss
  • Nausea and vomiting
  • Loss of appetite.
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