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Heartburn and indigestion are common but often mistaken for one another, so how can pharmacy teams help customers identify and tackle these different conditions?

About a quarter of UK adults will be waylaid at some point by heartburn and indigestion, making it highly likely that pharmacy teams will face questions about over-the-counter (OTC) solutions and self care advice regarding the conditions on a regular basis – but although symptoms can be similar, these two digestive upsets are not the same.

“Heartburn is chest pain, or a pain behind the breastbone, that occurs after eating, lying down, or bending over and is most usually described as ‘burning,’” explains Julie Thompson, information manager at Guts UK Charity. “Whereas for indigestion, on the other hand, most people have their own pattern of symptoms which range from mild discomfort in the upper part of the abdomen to quite severe pain, and other people can experience a more general feeling of fullness (heaviness or bloating) and discomfort in the upper abdomen after a meal, and also feel sick too.”

Pharmacy teams may find it challenging to help customers tell the two conditions apart because people can have symptoms of both at the same time, and they often use the terms interchangeably within conversations, but there are some key signs and symptoms that can help identify what they are dealing with.

In general terms, while the symptoms of indigestion usually occur after eating or drinking, heartburn often seems worse specifically after rich meals or drinking acidic fruit juice, hot drinks or alcohol, sometimes with discomfort or pain on swallowing, and symptoms are commonly worse at night or when lying down.

Heartburn and acid reflux

The main culprit when it comes to heartburn is a backwash of stomach acid travelling back up the oesophagus from the stomach, causing the familiar burning pain of heartburn.

As with so many common ailments, certain lifestyle choices are thought to increase the risk of heartburn and reflux, such as smoking, drinking excess alcohol, and being overweight. Many women also experience temporary episodes of heartburn during the later stages of pregnancy as the growing baby pushes upwards on the stomach. In addition, people with a hiatus hernia – where part of the stomach slides upwards into the chest through a hole in the diaphragm muscle – seem to be more prone to reflux.

Causes of indigestion

Although there is rarely a serious underlying condition causing indigestion, data from Guts UK suggests 80 per cent of people with indigestion are ultimately diagnosed with functional dyspepsia, which happens when the nerves in the stomach become overly sensitive, causing symptoms of pain. 

A much less common cause of indigestion is peptic ulcer disease, thought to affect eight per cent of people, and in rare cases indigestion may be a symptom of gallstones, pancreatic diseases or stomach cancer, but these conditions will often come with other symptoms as well.

“GORD is a common condition affecting one in 10 people”

Red flags

“Heartburn and indigestion can sometimes come with additional symptoms that indicate a more serious health concern,” says Julie Thompson, information manager at Guts UK Charity. These include:

  • Food getting stuck in the oesophagus, frequently being sick or experiencing unintentional weight loss
  • Heartburn most days for three weeks or more
  • Difficulty or pain when swallowing food
  • Heartburn symptoms with exercise
  • Blood in poo or vomit
  • A noticeable lump in the abdomen.

If lifestyle changes and pharmacy medicines aren’t helping, and/or if the person has had heartburn, indigestion, hiccups or an unpleasant taste in the mouth for three weeks or more, pharmacy teams should refer them to their GP.

Pharmacy advice

The good news is there is plenty of self care and OTC advice that pharmacy teams can give people to help them treat their heartburn and indigestion quickly and effectively.

General advice for addressing heartburn and reflux includes eating a healthy balanced diet, low in high fat or rich foods, and maintaining a healthy weight, or reducing body weight if this is above what is considered to be healthy. “This reduces pressure on the stomach”, says Julie, “but if the person is underweight, they should see their GP to ask for a referral to a dietitian for help, as weight loss when someone is underweight is not advisable”.

While some people find cutting down on fizzy drinks and those containing caffeine (tea, coffee and some energy drinks) can help, Julie says evidence for this is “inconclusive”. In addition, for some people spicy food and tomato are more likely to trigger symptoms. “Reduction of these foods might be helpful”, says Julie, “but there is no single approach to diet and reflux, and triggers can be very individual, so if the person is struggling they should ask their GP for a referral to a dietitian”.

Unsurprisingly, stopping smoking and reducing alcohol intake are also good ideas, but sometimes these lifestyle changes can be challenging for people. With that in mind, Julie says: “Most people do better with help. Anyone who has a high intake of alcohol or reports a dependency should be directed to their GP if they wish to reduce their intake, so that they can do this safely.” Of course many pharmacies also offer stop smoking services, or can refer customers to other smoking cessation services locally.

Since many people eat their largest meal in the evening, other good advice is to eat at least three hours before going to bed, avoiding high fat meals, and not laying flat once in bed. “Placing something under the head end of the bed to raise it or using a special wedge pillow is best”, says Julie, “but using two pillows is not generally helpful as most people can still end up lying flat during the night – sleeping on the left-hand side of the body can also help”.

Things like alcohol, caffeine and fried foods can trigger heartburn, so recommending
a healthy, balanced diet is good advice for customers.

OTC solutions

OTC medicines can help for short term symptoms of indigestion and heartburn and there is a range of them available to recommend, such as antacids, coating agents such as alginates, and proton pump inhibitors.

Antacids are chewable tablet or liquid medicines that neutralise stomach acid and help to relieve indigestion and heartburn. They are available either as well-known pharmacy brands or some are named after their main ingredient, which can include calcium carbonate, magnesium hydroxide, magnesium trisilicate, magnesium carbonate and aluminium hydroxide.

Best taken after meals and before going to bed, Jill Stuart, commercial director of FW Medical Ltd says these “will usually relieve symptoms in a few hours, although they do not treat the underlying cause of the indigestion”.

Some antacids are combined with coating agents called alginates which can help to reduce acid reflux and indigestion at the same time. Alginates form a thick protective layer on top of the stomach contents and help reduce reflux symptoms. These can be useful to take after meals and before going to bed to reduce night-time symptoms.

Then there are acid-supressing capsules or tablets which reduce the amount of acid produced by the cells in the stomach. Histamine H2-receptor antagonists (H2 blockers) include cimetidine, famotidine and nizatidine, and these can be taken prior to bedtime. Proton pump inhibitors (PPIs) work 

on the cells that line the stomach, reducing the production of acid, and include omeprazole, lansoprazole, esomeprazole and pantoprazole – which can be bought over the counter in pharmacies – and rabeprazole which requires a prescription. These are best taken 30 minutes prior to breakfast or evening meal, but Julie stresses that: “Medical advice should be sought if someone requires a PPI for more than four weeks”.

“Natural OTC alternatives are also available in the form of colloidal silica gel, which coats the stomach with a protective lining and adsorbs excess acidity and gas to help relieve symptoms of indigestion like acid reflux and heartburn,” adds Jill. “It can be taken with other medications as long as it is taken at least an hour before or after taking medicines, and it’s particularly helpful for night-time reflux if taken before bedtime.”

Oh good GORD

Gastro-oesophageal reflux disease (GORD) is caused by the reflux of stomach contents (which contains acids and enzymes) up into the food pipe or oesophagus, which over time causes damage and inflammation.

GORD is a common condition affecting one in 10 people, and while it can be attributed to several diseases of the digestive system, in up to 70 per cent of cases no cause is found. It is more common in individuals with a hiatus hernia, weaknesses of the sphincter muscle (the valve between the stomach and the oesophagus), and a Helicobacter pylori (H-pylori) bacterial infection – which a breath-test and course of antibiotics will help to identify and treat.

GORD is also more common in pregnancy, in people who are overweight, and in those over the age of 40. Diet and lifestyle factors may also play a role in symptom development.

How is GORD different from heartburn
and indigestion?

Although acid reflux is a symptom of GORD, there are other symptoms which differentiate it from simple indigestion or heartburn. These can vary from person to person and may be experienced frequently or only occasionally, including:

  • Feeling bloated and belching
  • Nausea and vomiting
  • Being unable to finish a normal sized meal
  • A sharp, burning pain below the ribs or shoulder blades
  • Tooth decay and gum disease
  • Sore throat and a persistent cough.

Proton Pump Inhibitors (PPIs) are the most commonly used drugs to treat GORD symptoms. Antihistamines such as ranitidine can be useful for people who experience side effects from PPIs, while OTC antacids can offer an immediate soothing effect.

Lifestyle and diet changes

Encouraging people to adjust some of their diet and lifestyle choices can improve GORD symptoms enough to enable for some to come off medications entirely.

For example, pharmacy teams can advise customers to:

  • Stop smoking
  • Reduce stress
  • Take regular exercise
  • Aim for a healthy body weight
  • Avoid tight fitting clothes (especially after eating)
  • Avoid heavy exercise immediately after eating
  • Avoid bending down or lifting heavy objects after eating
  • Avoid eating late at night and laying down flat after meals.
  • When it comes to food, pharmacy teams can suggest that customers:
  • Avoid or limit alcohol and caffeine
  • Avoid or limit fried breakfasts, crisps, chips, pastries, pies, pizza, battered and deep fried foods, sausages, full fat milk, mayonnaise, cakes and biscuits
  • Avoid having large meals
  • Eat smaller, more frequent meals and avoid long periods without eating
  • Aim for a healthy, balanced diet to ensure intake of essential nutrients – and consider taking a multivitamin and mineral tablet if they are concerned
  • Eat slowly and chew food well.

Some people find coffee, fizzy drinks, onions, chocolate and cocoa, citrus fruits or juices, garlic, spicy foods, high fat foods, tomato-based foods and processed meats may make their GORD symptoms worse, so this is where keeping a food diary can be handy. Food sensitivities vary from person to person so suggesting that the person keeps track of their symptoms over a few weeks can help pinpoint what foods could be making these worse.

As with heartburn and indigestion, there are some additional symptoms that may come along with GORD and indicate a more serious condition. Pharmacy teams should be alert to people reporting vomiting blood or vomiting regularly over a period of time, experiencing difficulties swallowing foods, or ongoing unintentional weight loss and refer them to their GP for further follow-up.

“80 per cent of people with indigestion are ultimately diagnosed with functional dyspepsia”

The stress link

It is important that mental health conditions such as stress, anxiety, and depression are also recognised as a possible cause of digestive problems, with research showing the inability to adapt to stress can trigger and worsen the symptoms of many gastrointestinal disorders. Short-term stress can lead to loss of appetite and slow digestion, medium-term stress can trigger constipation, diarrhoea or indigestion, and long-term can lead to more serious disorders such as irritable bowel syndrome (IBS) or inflammatory bowel disease (IBD).

It is also possible that living with digestive upsets can affect people’s mood, too, so customers experiencing unpleasant symptoms will benefit in more ways than one from supportive advice from the pharmacy team.

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