Of the many potentially embarrassing problems people can come to a pharmacy with, digestive health complaints rank somewhere near the top. Many digestive complaints, such as heartburn, indigestion and constipation are self-limiting, making pharmacy the perfect place for a customer’s first port of call when experiencing problems. This means pharmacy staff must be prepared to deal with digestive health issues as sensitively, patiently and empathetically as possible.
The range of issues that can affect the gut is huge. A survey by YouGov of 984 people found the most frequently experienced digestive symptoms in the UK were:
Of those surveyed just 41 per cent had been to a doctor for help with these complaints, with most reporting their symptoms were resolved without needing a GP consultation.
This again suggests that pharmacy should be ready to step in as an important first port of call for advice and recommendations.
While it is important to rule out more serious or underlying medical problems, many digestive complaints are affected by diet and so relatively simple steps can be taken to improve symptoms.
However, Rachel Wilson, pharmacist at Lindsay and Gilmour Pharmacy’s Forth branch near Glasgow sees many patients come in with digestive complaints who want a quick fix and aren’t necessarily prepared for the lifestyle changes they may need to make. “The fact is the majority of digestive tract issues are related to diet in some capacity, which people don’t want to hear as they want a nice quick fix, but unfortunately if it is an ongoing problem they need to look at how much fibre they are taking in and how much fluid,” she explains. “It’s always worth pressing the concept of two litres of fluid a day. It makes you think ‘oh I have a cup of tea in the morning and a cup of tea at night’ but that is not enough fluid to keep the digestive tract healthy.”
Stress can also have a significant impact on the gut, with a growing body of evidence highlighting that stress can cause inflammation, as well as disrupting the symbiotic relationship between the gut microbiome and the brain, which in turn can affect mental health. It is therefore worth considering the impact of stress and mental health on the gut health, particularly with regards to IBS (see below).
Closely linked to stress is embarrassment. Being embarrassed about a problem is inherently stressful, making it difficult to disentangle the two. Rachel suggests keeping an eye out for patients who may seem a little shy and hesitant when they come into the pharmacy and asking them if they would like to have a private chat in the consultation room.
“Have a chat and just be very factual about it”, she says, adding that it can be a good idea to compliment people for seeking help rather than letting a problem continue to impact on their lives. This kind of empathetic treatment may encourage an individual to use the pharmacy again in the future if another minor ailment was bothering them.
People who come into the pharmacy for advice about diarrhoea are most likely to be presenting with an acute problem, which means it will be short-term rather than long lasting.
Common causes of diarrhoea include:
If diarrhoea symptoms last longer than three days, customers should be advised to see their GP, advises Rachel. She also suggests asking questions to see if there is an underlying problem: have they been travelling recently? Is this a common problem for them? Has it been ongoing?
Anyone experiencing short-term diarrhoea with no apparent complications should focus on avoiding dehydration as first-line management. “If it is straightforward diarrhoea, say from a bug or something, then dehydration is the main thing to avoid. You can also use loperamide to stop the diarrhoea, but sometimes it is better to let it pass through the system and to make sure you rehydrate yourself properly,” Rachel Wilson, pharmacist at Lindsay and Gilmour Pharmacy in Forth, explains. If customers choose to take loperamide because they are otherwise well and having diarrhoea is an inconvenience, they should take this alongside rehydration treatment. Children should be treated with rehydration solutions and watched for signs of dehydration, such as not urinating frequently.
It’s always worth pressing the concept of two litres of fluid a day
While diet and stress are common causes of digestive discomfort, there are other more serious causes of these conditions and so it’s important for pharmacy teams to be aware of the red flags that warrant referral for further investigation.
If a customer has been using an OTC remedy for two weeks or more and not seen an improvement in their symptoms, they should be advised to see their GP. In addition, the NHS highlight five symptoms that require an urgent GP appointment:
These symptoms could be signs of serious illness. For example bleeding from the bottom is associated with bowel cancer and recurrent indigestion that does not respond to OTC treatment can be a sign of pancreatic cancer. As with most conditions, these are easier to treat if they are found early and so immediate referral is particularly important. Certainly for pancreatic cancer, those diagnosed early and in time for surgery see their chances
of survival increasing by up to 30 per cent.
Constipation is common. So common in fact that people sometimes do not realise that they are constipated. This means people often leave it six to 12 months before seeking help, researchers at King’s College London warned earlier this year.
The current NHS definition for constipation in both adults and children, is opening bowels fewer than three times a week. Rachel Wilson, pharmacist at Lindsay and Gilmour Pharmacy in Forth, says she thinks it is also well defined as a change in bowel habits for patients and advice should lead from there.
“If it is a short-term problem, they don’t have any other symptoms and it is straight forward constipation then they can just take something to move things along. They can then take some lactulose or if they need something a bit stronger, maybe senna. If it is something longer-term then they will need a longer-term treatment to get their bowel habit back.”
There are a number of longer-term causes of constipation that also need to be considered. Pregnant women and women who have recently given birth may be constipated. Extra consideration is required for the types of medicines that are appropriate for these customers and so they should be referred to the pharmacist.
Irritable bowel syndrome and some bowel diseases can also cause constipation and it is important to question patients about how long these symptoms have been going on, if they have been accompanied by any others, and if necessary refer them to their GP.
Of course, diet is an important consideration and all customers suffering from constipation should consider increasing their consumption of fibre and water.
The last few years have seen a growing interest in the gut microbiome and its impact on health. This has in turn led to an increased interest in probiotics and whether or not they can help treat a range of digestive complaints.
Probiotics – commonly known as friendly bacteria – are live bacteria and yeasts that are promoted as having various health benefits, including supporting healthy immune, digestive, and respiratory systems. In the case of the digestive system, probiotics are thought to help restore the natural balance of bacteria in the gut when it’s been disrupted by an illness or treatment.
Finding evidence for probiotics benefitting gut health is complex as they are classified as either foods or dietary supplements rather than medicines by the Medicines and Healthcare products Regulatory Agency (MHRA) and therefore do not go through the same rigorous testing.
The NHS states that there is some evidence that probiotics could help prevent diarrhoea when taking antibiotics, or with some IBS symptoms, but warns there is a potentially big difference between taking pharmaceutical-grade probiotics and consuming yogurts and supplements that contain probiotics. In addition, as people’s gut microbiomes vary so much, a probiotic that seems to have benefits for one person might not for another and if a probiotic works for one gut problem, there is nothing to say it will work for a different one.
Hannah Braye, a technical advisor at Protexin, says: “Pharmacies will be doling out antibiotics to a lot of people so hopefully now [they] are educated enough about probiotics so that if someone is coming in to pick up an antibiotic prescription then they should be recommending probiotics to be taken alongside to reduce the risk of antibiotic diarrhoea.”
Hannah recommends a multi-strain probiotic for people who have IBS symptoms as these have demonstrated the most efficacy in clinical trials. “There is evidence to suggest increased synergistic effects of multi-strain products, for example, such as increased pathogen inhibition and increased adherence of the bacteria to the lining of the gut. Different strains also exert their effects in different parts of the digestive tract, so multi-strain products may provide more all-round support,” she adds.
Heartburn is a burning feeling in the chest caused by stomach acid travelling up towards the throat. It can leave an unpleasant taste in the mouth, as well as other symptoms such as a cough or recurring hiccups, a hoarse voice, bad breath, bloating and feeling sick.
Many people blame rich fatty foods as well as alcohol for worsening their heartburn, but they are far from the only culprits. Caffeine, spicy food and chocolate also contribute.
Being overweight, smoking, stress, anxiety and some medications are also risk factors, and pregnancy hormones mean many pregnant women are more likely to suffer from heartburn.
Indigestion is caused by excess acid in the stomach irritating the lining. Most people will experience this from time to time, but should seek help from a GP if they have ongoing symptoms, as it could be a sign of something more serious.
Pharmacy staff can suggest antacids, which are available in tablet or liquid forms, to people suffering from heartburn and indigestion. Proton pump inhibitors, such as omeprazole and esomeprazole, which limit stomach acid production, are also available OTC in pharmacy, which may
be useful to some patients.
There is a range of self care measures that can be suggested to customers to help manage symptoms. These include:
Irritable bowel syndrome (IBS) encompasses a whole range of issues that can include bloating, cramps and abdominal pain, as well as changes in bowel habits. As many as one in eight people may be experiencing IBS symptoms at any one time and it is thought that IBS is caused by extra sensitivity in the gut. It can sometimes cause the passage of food through the gut to speed up, which is why it can cause diarrhoea and flatulence.
Changes to diet are often recommended and antispasmodic drugs may be helpful for some people. Loperamide can be used for diarrhoea, where appropriate, and some people may find peppermint oil capsules helpful.
Customers who have these symptoms over a long period of time should see their doctor so as to have other potential problems, such as inflammatory bowel disease (IBD) or coeliac disease, ruled out.
There is also a link between stress and IBS and therefore tackling the underlying stress may help. Some people may turn to therapy in order to achieve this.
Professor Stephen Palmer, a psychotherapist and member of the British Psychological Society, has patients come to him to access cognitive behavioural therapy to help with their IBS. “If we analyse and keep a diary of what seems to trigger [my patients’ IBS], more often than not it is nothing to do with the food or anything else that is going on,” he says. “Often it is something that triggers stress or anxiety. So maybe it is a social situation or maybe at work they don’t like doing a presentation or something like that, and the stress and anxiety seems to be triggering the symptoms they have got.”
He acknowledges that the symptoms are not very pleasant, which can make people more anxious, but suggests that various types of therapy could be used from mindfulness and CBT, through to psychotherapy and counselling.