Hard to stomach

When are tummy troubles a sign of something more serious than indigestion?

We all suffer from an upset stomach now and again – especially at times of the year like this, when overindulgence is often the order of the day – and lots of people claim to have allergies to all sorts of foods that they say cause them digestive problems. But when do grumbling tummies become a sign of something more than just too much of a good thing?

Coeliac disease is not an allergy or an intolerance, but an autoimmune disease where the body’s immune system reacts when gluten – a protein found in wheat, barley and rye – is eaten, causing damage to the lining of the small bowel. It is associated with chronic inflammation of the small intestine, which can lead to malabsorption of nutrients. According to NICE, it is a common condition, and studies suggest that in the UK, one in 100 people are affected. As yet, there is no cure and there is no medication. The only treatment is a strict gluten-free diet for life, with potential serious long-term health complications of not maintaining a gluten-free diet including osteoporosis, infertility and, in rare cases, small bowel cancer.

Coeliac UK estimates that there are around half a million people in the UK living with the disease without knowing it. This is because milder cases may go undiagnosed or be misdiagnosed as other digestive conditions, such as irritable bowel syndrome (IBS). However, a pilot study funded by the charity claims that community pharmacies can play a vital role in identifying patients with undiagnosed coeliac disease, speeding up diagnosis. 

The great pretender

Dr Gianluca Ianiro, spokesperson for United European Gastroenterology (UEG), says the disease is often called the ‘great pretender’, as it can simulate many other disorders. This means it remains underdiagnosed, particularly when people present in primary care settings, such as community pharmacy. Delayed diagnosis is a concern because of the possible long‑term complications. Norma McGough, director of policy, research and campaigns at Coeliac UK, says: “If people have been diagnosed with irritable bowel syndrome but have not been tested for coeliac disease, they should be screened for coeliac disease by the GP.” 

So how can you help detect coeliac disease? Gillian Stone, pharmacist at Well, advises pharmacy teams to look out for customers asking for advice or purchasing products to help with ongoing gastrointestinal symptoms such as severe diarrhoea or bloating, wind, constipation, persistent nausea or vomiting. “These symptoms, along with tiredness, depression and hair loss, can be a sign that the customer has coeliac disease,” she says. 

Sajdah Amin, LloydsPharmacy pharmacist, believes that by just asking people how they feel, it’s possible to identify customers who have some or all of the symptoms of coeliac disease. “When customers visit us for general OTC products, we can talk to them about their symptoms and recommend the appropriate treatment,” she says.

People with conditions such as type 1 diabetes, autoimmune thyroid disease, Down’s syndrome and Turner syndrome are also at a higher risk than the general population of having coeliac disease, and first‑degree relatives of a person with coeliac disease also have an increased likelihood.

As people with type 1 diabetes can be more at risk of coeliac disease, Dr Ianiro emphasises that patients “should be advised to check for coeliac disease regardless of symptoms, as these two disorders are closely associated”.

Sajdah suggests that: “As a proactive measure, you may want to consider screening diabetes patients, even if they show no symptoms. You can ask a diabetes patient how they’re getting on with their insulin; do they have any recurrent hypoglycaemia; any sweating, anxiety, hunger, tremors or palpitations? These extra symptoms can often be signs of underlying digestive conditions.”

This is because, as Gillian explains: “Coeliac disease affects the absorption of food from the gut, so people who also have coeliac disease may also have frequent hypoglycaemia, as the insulin required is less predictable. For those who have type 1 diabetes, insulin requirements will need to be carefully monitored and adjusted as wheat is excluded from the diet.”

Signs and symptoms

Spotting the symptoms of coeliac disease could be a turning point for anyone who is so far undiagnosed. For example, stomach ache, constipation and bloating are often attributed to IBS, but for one in 100 people they indicate coeliac disease.

Ewa Gabzdyl, pharmacist and adviser to charity The IBS Network, suggests starting by asking patients about their bowel habits and looking out for symptoms of IBS, such as unresolving diarrhoea, constipation, straining, urgency, incomplete evacuation, passage of mucous, abdominal pain and discomfort, bloating (more common in women than men), distension, tension or hardness.

In addition to gastrointestinal problems, Ewa says coeliac disease could be suspected if the customer reports any of the following:

  • Faltering growth in children
  • Prolonged fatigue
  • Unexpected weight loss
  • Severe or persistent mouth ulcers
  • Unexplained iron, vitamin B12, or folate deficiency
  • Autoimmune thyroid disease.

Any of these should prompt you to refer your customer to see their GP, who may consider diagnostic tests to confirm diagnosis and encourage them to exclude gluten from their diet under the supervision of a registered dietitian.

Advice and signposting 

Thankfully, most people with coeliac disease report a rapid clinical improvement after starting a gluten‑free diet. NICE points out that specific education and information, such as advice on alternative foods to maintain a healthy and varied diet, may increase the likelihood of adherence and a positive prognosis, and there is much that pharmacy teams can do to help customers get all the information they need. For example, Norma says: “Pharmacy staff have a role in ongoing management in terms of access to gluten-free food on prescription and may also be able to provide ongoing advice on the need for referral to a dietitian or GP if it appears there is a need for clinical review.”

For those who have just been diagnosed, Gillian says: “We would encourage pharmacy staff to suggest that the patient contacts Coeliac UK for further support and information, and finding local groups within the immediate locality is really important too.”

Armed with the right knowledge, pharmacy staff are in the ideal position to help customers understand the condition and better manage their symptoms so they can get the right advice earlier – and maybe even save their life.

Combat common complaints

Heartburn and indigestion

Heartburn and indigestion – or dyspepsia – cause discomfort and pain in the upper gastrointestinal tract. Heartburn occurs when stomach acid leaks back up into the oesophagus, causing irritation and a burning pain behind the breastbone. Indigestion occurs when stomach acid comes into contact with the lining of the digestive system, causing pain in the upper abdomen, belching, nausea and a feeling of fullness. Eating certain foods, drinking alcohol, smoking, being pregnant and even certain medication can trigger symptoms. The good news is that, unless there is a more serious underlying health problem, most cases can be treated simply and effectively with lifestyle changes and OTC medicines.

  • Lifestyle changes

Simply consuming less food is a good place to start, as is cutting down on high-calorie, spicy or fatty foods, alcohol and caffeinated or fizzy drinks. Advise customers to look out for particular foods or drinks that make their symptoms worse and avoid them. 

Being overweight is also something to address. Carrying extra pounds puts pressure on the stomach and encourages acid to be pushed back up into the oesophagus. Similarly, smoking can exacerbate acid reflux, as the chemicals contained in cigarette smoke relax the oesophagus and let stomach acid leak back upwards. If your pharmacy offers weight loss or smoking cessation services then encourage customers to consider making use of these to help them lose weight or kick the habit, which might also help with their digestive problems.

For customers who seem only to get symptoms at night, advise them to eat their last meal earlier in the evening in order to avoid going to bed with a full stomach, or to prop themselves up with a few pillows to prevent stomach acid travelling up into their oesophagus while they sleep.

  • Suitable medicines

If a customer is looking for relief that is a bit more instant, there are various OTC treatments to recommend. 

For fast relief after a short-term period of overindulgence, OTC antacids, which neutralise excess acid in the stomach, can be a suitable option. Some antacids also contain alginates, which help relieve heartburn symptoms by forming a ‘raft’ that floats on top of the contents of the stomach to stop acid leaking back up into the oesophagus. These should be taken after eating.

If your customer is suffering from recurring symptoms, a longer-lasting product containing an H2 antagonist or proton pump inhibitor may be more suitable. 

If symptoms are not relieved or are severe, a GP may test for Helicobacter pylori (H. pylori) bacterial infection, which increases stomach acid and can cause bloating, belching, nausea, vomiting, abdominal discomfort and fatigue. Treatment consists of antibiotics and a proton pump inhibitor, with just one course
of therapy effective in 85 per cent of cases.


Constipation is a condition of the digestive tract where the passage of the waste through the bowels is slow, difficult to expel and sometimes painful. The most common cause is excessive absorption of water by the colon, arising from insufficient fluid or fibre in the diet, a lack of exercise, certain medications – such as codeine, iron, diuretics and certain antidepressants and indigestion remedies. Illnesses that slow the passage of the stools through the bowel can also be a cause. 

The patient may notice abdominal discomfort, bloating, straining and a sensation that their bowels are never completely emptied. An occasional bout of constipation is quite normal, but frequent or persistent constipation is not and should be referred on to the pharmacist. Patients should also be referred immediately if there are additional warning signs, such as bleeding, alternating constipation and diarrhoea, mucus or a blockage.

The first line of treatment is to address the person’s water balance and then the bulk of their bowel contents, in three stages:

  • Increase dietary fluid intake – to at least seven to eight glasses of fluid daily and try a suitable laxative (usually osmotic or bulk forming)
  • Follow up with an increase in dietary fibre. If this plan doesn’t work, think about the patient holistically and in detail, considering information such as stress and activity levels
  • If the patient is still suffering, they could ask the pharmacist about options such as stimulant laxatives, suppositories and enemas.


Diarrhoea will usually clear up without treatment after a few days, particularly if it’s caused by an infection. In children, diarrhoea will usually pass within five to seven days and rarely lasts longer than two weeks.

It is important to drink plenty of fluids – small, frequent sips of water – to avoid dehydration, particularly if the sufferer is also vomiting. Ideally, adults should drink a lot of liquids that contain water, salt, and sugar, such as soup broth or water mixed with juice.

An oral rehydration solution (ORS) can help to prevent dehydration for at-risk patients such as the frail or elderly. Antidiarrhoeal medicines such as loperamide may help reduce diarrhoea and slightly shorten how long it lasts, but are not usually necessary.

Coeliac disease is often called the ‘great pretender’, as it can simulate many other disorders

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