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Something serious?

It’s not easy for everyone to admit to bowel health problems, but some are more serious than others and early advice from the pharmacy team could prove to be lifesaving

From stomach ache and bloating to bouts of constipation or diarrhoea, everyone will have experienced their bowels playing up at some point in their lives. For most people, it may be a tummy bug or a spot of over-indulgence, but for others, there may be underlying issues that need to be addressed.

Knowing the warning signs of when a customer’s seemingly simple enquiry about their bowel health could be something more serious is important for all pharmacy teams, as well as being aware of the next steps that should be taken and the support that’s available.

Inflammatory bowel disease

At least 300,000 people in the UK live with inflammatory bowel disease (IBD), and every 30 minutes someone in the UK is diagnosed with Crohn’s disease or ulcerative colitis – the two main forms. While ulcerative colitis only affects the colon (large intestine), Crohn’s disease can affect any part of the digestive system, from the mouth to the anus.

IBD can affect people of any age, but it is usually diagnosed between the ages of 15 and 40. It is thought to be caused by a combination of factors, including genetics – an individual is more likely to get IBD if they have a close relative with the condition – or a problem with the immune system. Smokers are also twice as likely to get Crohn’s disease than non-smokers.

Symptoms of IBD include pain, cramps or swelling in the stomach; recurring or bloody diarrhoea; weight loss; and extreme tiredness. These symptoms can flare up and be followed by long periods of remission.

There is currently no cure for ulcerative colitis or Crohn’s disease, and treatment – such as specific diets, lifestyle changes, medicines and surgery – aims to relieve the symptoms and prevent them from returning.

Every 30 Medicines to treat ulcerative colitis or Crohn’s disease include:

  • Aminosalicylates or mesalazines, which can reduce minutes inflammation in the gut 
  • Immunosuppressants such as steroids or azathioprine to reduce the activity of the immune system
  • Biological and biosimilar medicines, which are antibody-based treatments given by injection that target a specific part of the immune system
  • Antibiotics.

Julie Thompson, information manager at the charity Guts UK, says there are some red flags that pharmacy teams should look out for in customers who are known to have IBD. These include “fever, change in bowel habit, blood in stools, weight loss, vomiting and abdominal pain”. If a customer presents with any of these symptoms, refer them to the pharmacist as they may need to contact their IBD treatment team, if they have one.

Every 30 minutes someone in the UK is diagnosed with Crohn’s disease or ulcerative colitis

Irritable bowel syndrome

Irritable bowel syndrome (IBS) is a common disorder of the gut-brain interaction, which leads to abdominal pain, bloating, diarrhoea and/or constipation. It is thought to affect up to 12 million people in the UK.

Symptoms can include constipation, diarrhoea, abdominal cramps, pain and bloating, tiredness, nausea, heartburn and indigestion, backache, needing to pass urine frequently, headaches, muscle pain, anxiety and depression.

“There is no specific cause for IBS and no single effective treatment,” says Alison Reid, chief executive of The IBS Network. “It is important to receive a diagnosis based on a typical history and examination and have been tested to exclude other conditions, such as coeliac disease and inflammatory pathology, within the gut.”

Once a person has an IBS diagnosis, considering their diet and lifestyle is the first-line treatment. “Start by encouraging 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,” says Alison. “They can then use this information to better understand their symptoms and triggers and identify any patterns to their IBS.”

The next step is to recommend they:

  • Eat three to four meals a day, avoiding spicy or fatty foods
  • Drink plenty of fluid, especially water
  • Limit alcohol intake to no more than two units per day and have at least two alcohol free days a week
  • Reduce caffeine intake
  • Limit fresh fruit to three portions per day.

Of course, if a customer complains of any of the red flag symptoms, such as bleeding from the rectum, change in bowel habit for no obvious reason, weight loss when they are not trying to lose weight or a persistent fever, they should be referred to a GP.

Unintentional weight loss should be investigated as it can indicate a serious bowel
condition.

Coeliac disease

Coeliac disease (pronounced see-lee-ac) is a lifelong autoimmune disease caused by a reaction to gluten – a protein found in wheat, barley and rye – and a similar protein called avenin that is found in oats. When someone with coeliac disease eats either of these proteins, the body’s immune system attacks its own tissues, which causes damage to the lining of the gut.

“Coeliac disease is common and affects around one in 100 people,” says Ruth Passmore, head of health policy at the charity Coeliac UK. “However, only approximately 30 per cent who have the condition have currently been diagnosed, so there are nearly half a million people who have coeliac disease but don’t yet know.”

In a community pharmacy setting, coeliac disease can present a range of symptoms that may vary from person to person. These can include:

  • Persistent constipation, diarrhoea, feeling sick and vomiting
  • Unexpected weight loss
  • Faltering growth in children
  • Feeling tired all the time
  • Severe and persistent mouth ulcers.

As many of the gut symptoms are similar to those of IBS, Ruth says: “A test for coeliac disease should be carried out before a diagnosis of IBS is made.”

The only treatment is strict, lifelong adherence to a gluten free diet, and Ruth says pharmacy teams can play a key role after diagnosis by providing information on the gluten-free diet, including information on gluten-free foods available on prescription. “You can also remind patients there are some vaccinations which are recommended for people with coeliac disease,” says Ruth. Information on both of these can be found at Coeliac UK.

Remember to respect the customer’s privacy and talk out of earshot of other customers

Is there any evidence?

Over the years, there have been many studies on the beneficial effects that probiotics – or so-called friendly bacteria – and prebiotics may have on the gastrointestinal tract.

“Probiotics may be helpful in the treatment of inflammatory enteral conditions, including ulcerative colitis, Crohn’s disease and non-specific ileitis,” says Mike Wakeman, clinical pharmacist and spokesperson for the Alive! range of vitamins and minerals. “Numerous studies [have] assessed the use of probiotics in the treatment of lactose intolerance, irritable bowel syndrome, and the prevention of colorectal cancer and peptic ulcers, and there are many reports on the application of probiotics in the treatment of diarrhoea.”

When it comes to prebiotics – dietary fibres that feed the friendly bacteria in the gut – Mike says: “Animal studies have shown that short-chain fatty acids produced by the fermentation of prebiotics can regulate gut hormones that in turn modulate the local motor responses of the gut. The humectant – or water binding capacity – of prebiotic carbohydrates also has the effect of softening stools, making passage easier.”

Alison Reid, chief executive of The IBS Network, says: “The NICE guidelines for IBS suggest that probiotics be trialled for at least a month to ensure the best results, and the IBS Network also recommends that if one probiotic is not effective, it is worth trying a couple more brands.”

However, if pharmacy teams are recommending any of these products and strategies to customers, Mike stresses that they should read up on the data to make sure the advice is “specific and appropriate” to their individual needs.

Bowel cancer

Bowel cancer is one of the most common types of cancer in the UK and most people diagnosed are over the age of 60. The exact cause is not known.

The main symptoms of bowel cancer are a persistent change in bowel habit; persistent blood in stools; and persistent lower abdominal pain, bloating or discomfort always caused by eating and possibly associated with loss of appetite or significant unintentional weight loss.

Red flags to look out for, according to Julie, include “other symptoms that might suggest investigation for metastatic spread [the spread of cancer cells to other areas of the body], such as jaundice, shortness of breath and cough”, at which point pharmacy teams should strongly encourage the customer to see a GP immediately.

The NHS offers two types of bowel cancer screening to adults registered with a GP in England. All men and women aged 60 to 74 are invited to carry out a FIT or FOB test every two years, using a home test kit. Anyone aged 75 or over can request this test by calling freephone: 0800 707 60 60. An additional one-off test called ‘bowel scope screening’ is gradually being offered in England to people at the age of 55. This involves a doctor or nurse looking inside the lower part of the bowel using a camera on the end of a thin, flexible tube.

It is worth encouraging customers to take part in bowel cancer screening, as removing any polyps – small growths that can develop on the inner lining of the rectum – found during bowel scope screening can prevent cancer.

Depending on how far it has spread by the time it is diagnosed, bowel cancer can be managed using a combination of treatments including surgery, chemotherapy, radiotherapy, and targeted therapies – a newer group of medicines that increase the effectiveness of chemotherapy and prevent the cancer from spreading.

As ever, prevention is better than cure, and there are several ways people can lower their chances of developing bowel cancer that pharmacy teams are ideally placed to advise customers about. Like so many aspects of health maintenance, these include stopping smoking and cutting down on alcohol, eating a healthy balanced diet, losing weight and keeping fit.

  Further information

•  Coeliac UK has an online learning programme specifically designed for pharmacy staff. You can also keep up to date on the latest developments by joining Coeliac UK’s free Healthcare Professional membership

•  Guts UK has leaflets on all the above diseases available

The IBS Network also has a range of educational materials.

Broaching sensitive subjects

Although pharmacy teams may be familiar with the symptoms and treatments for these problems, and be happy to discuss them, customers may feel awkward or embarrassed. Here are some tips to help with these conversations:

  • Privacy: remember to respect the customer’s privacy and talk out of earshot of other customers or, if appropriate, use a consultation room. This can mean that customers are more likely to speak openly, as they know the conversation is not being overheard
  • Body language: maintain open, relaxed body language as this will help the customer to feel at ease. Acting cagey or uncomfortable means customers will be less likely to open up about any problems they are experiencing. This is especially true if the subject is sensitive
  • Confidence: try not to feel awkward, as the customer will pick this up. Practising these conversations with colleagues may help. If a member of the team doesn’t feel comfortable discussing bowel health, the customer can be referred to a more experienced colleague or to the pharmacist
  • Language: try to reflect the type of language the customer uses – if they use the word “piles”, you should also say piles because saying haemorrhoids instead may cause confusion. The same goes for bowel movements – reflect the customer’s terminology
  • No judgement: take care when giving lifestyle advice not to make assumptions or judgements. For example, rather than saying “you should eat more fibre”, try something like “some people don’t always eat enough fibre, and that can cause constipation. Do you think that might be an issue for you?”

No matter how tactful a conversation is, the fact remains that many people will be embarrassed to talk about their bowel health. Being able to recognise those who may need advice and offering them appropriate support could make all the difference when it comes to spotting serious bowel health problems early and making individuals feel more comfortable.

Smokers are twice as likely to get IBD than non-smokers. 

Tackling common issues

As well as the more serious bowel problems previously discussed, there are several common bowel conditions that people may visit a community pharmacy for in order to receive advice and product recommendations.

Constipation

Constipation is a condition of the digestive tract where the passage of waste through the bowels is slow, difficult to expel and sometimes painful. Signs of constipation include abdominal discomfort, bloating, straining and a sensation that the bowels are never completely emptied.

The most common causes are excessive absorption of water by the colon, arising from insufficient fluid or fibre in the diet; a lack of exercise; certain medications; and illnesses that slow the passage of the stools through the bowel. Stress can also bring on constipation, as well as diarrhoea, and ignoring the urge to go is often a cause too.

Prevention is better than cure, but for those already suffering, the mainstay of treatment is to increase fluid intake to at least seven or eight glasses daily, coupled with eating more dietary fibre and at least five portions of fruit and vegetables a day.

Diarrhoea

Diarrhoea is common in adults, children and babies. Often caused by a stomach bug, it usually stops within a week and is simple to treat at home.

The most important thing is to have lots of fluids to avoid dehydration, drinking it in small sips to avoid feeling or being sick. Opinion is divided as to whether people should avoid any specific foods, but the general concensus is for people to eat solid foods as soon as they feel able. NHS advice is for sufferers to stay off school or work until they have not been sick or had diarrhoea for at least two days.

Taking paracetamol can help to deal with any discomfort – although customers should be reminded to check the patient information leaflet before giving it to a child. If they are showing signs of dehydration, such as dark and strong-smelling urine, oral rehydration sachets can be recommended for those over five years of age. A pharmacist may recommend medicines such as loperamide to people over 12 years of age. These can help slow down movement in the gut and decrease bowel movements for a few hours.

Haemorrhoids

Haemorrhoids – commonly known as piles – are painful, itchy lumps that develop inside and around the anus. Symptoms include bright red blood after passing a stool, the feeling of not having completed a bowel movement, or slimy muscus in underwear or on toilet paper after wiping.

Piles often get better on their own after a few days, and there are several ways to prevent and treat them. Drinking lots of fluid and eating plenty of fibre will keep stools soft. Regular exercise and cutting down on alcohol and caffeine to avoid constipation can also help. Sufferers can take paracetamol if the piles hurt. However, they should not take painkillers that contain codeine, as these can cause constipation, nor take ibuprofen if their piles are bleeding. There are creams available over the counter to ease the pain, itching and swelling.

Treatments such as laxatives may be suitable to help constipation and soften stools, which a pharmacist may recommend in some cases.




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