On the case with four common GI conditions
In this article you will learn about: ● How to identify heartburn and advise customers on treatment and prevention ● The possible causes of IBS and which products can be used to manage the condition ● The causes of constipation and the different treatments available ● How to advise customers with diarrhoea and decide what is the most appropriate course of action
Case 1: Heartburn
A woman asks you to recommend something for heartburn. Using the WWHAM questions you discover she has had heartburn symptoms on and off for the past few days, when previously she has only suffered occasionally after eating a large meal. She has not taken anything for it yet and is 20 weeks pregnant.
Heartburn is a condition where stomach acid moves up into the oesophagus or gullet. The acid irritates the lining of the oesophagus causing pain and discomfort. Heartburn can be caused by large, fatty or spicy meals, eating too late at night, extra pressure in the abdomen in pregnancy, being overweight or wearing tight clothing, smoking or drinking too much alcohol, tea or coffee.
Simple antacids such as sodium bicarbonate, calcium carbonate or magnesium carbonate, are usually the first thing to try. They neutralise stomach acid and relieve the irritation.
Some antacids are also available with an alginate, which forms a raft on top of the stomach acid, preventing it moving up into the oesophagus, and is especially useful in heartburn. As these products are usually in liquid form, they work more quickly than tablets, but are less convenient to carry around.
H2 antagonists such as ranitidine and famotidine and the proton pump inhibitors (PPIs) omeprazole and pantoprazole all work by reducing the amount of acid produced by the stomach. As tablets, they are more convenient to take, but should only be used for up to two weeks at a time.
Patients complaining of symptoms lasting longer than a few days with no obvious cause should be referred to their GP, as they may have a more serious condition such as a stomach ulcer.
In this case study, the symptoms are likely to be caused by the woman's pregnancy, and can be treated with an antacid or alginate product. However, as she is pregnant, you should refer her to the pharmacist.
Case study 2: Irritable bowel syndrome
A young man approaches the counter asking for something to treat irritable bowel syndrome (IBS). He has had it diagnosed by the GP and most of the time does not need any treatment, but it seems to be worse at the moment with diarrhoea and cramps. IBS is a common disorder affecting women more than men. The exact cause is unknown, but it may be a reaction to gastroenteritis, food intolerance or a disorder of the smooth muscle in the intestine. It often flares up during times of stress or anxiety; other triggers include a lack of fibre in the diet or laxative abuse. Common symptoms include:
● diarrhoea and/or constipation, often alternating between the two ● small, hard, pellet-like stools ● belching and flatulence ● abdominal rumbling ● bloating ● severe abdominal pain, often low in the abdomen, that is relieved by going to the toilet.
IBS is influenced by lifestyle and can be managed by taking steps to reduce stress. Eating a balanced diet, having regular meals, drinking plenty of fluids, not rushing when eating and taking regular exercise can all help to reduce the symptoms.
If lifestyle changes are not enough to manage the condition, there are medicines available. Selecting the best product will depend on which symptoms the patient finds most severe, and they may need to use different products depending on the main symptoms affecting them at that time.
Antispasmodics such as peppermint oil, hyoscine and mebeverine relieve the muscle contractions that cause abdominal pain. Constipation and diarrhoea can be treated using the medicines discussed below.
Products to treat the symptoms of IBS can be sold only if the patient has had the condition diagnosed by their GP. Even though the diagnosis has been made in this case, it would still be worth asking if the patient can think of anything that may have triggered the condition – additional stress for example. You should also check if they have any other symptoms, such as a fever, which may indicate this is not an IBS flare up.
Case study 3: Constipation
An elderly woman asks for something for constipation. She likes to go every day but finds she does not always need to.
Constipation is a reduced frequency of bowel movement compared with the normal for that person, usually with difficulty in passing stools and discomfort or pain. Normal frequency varies from person to person and can be anything from three times a day to three times a week; the important thing is a change from normal.
Common causes of constipation include: too little fibre in the diet; not drinking enough fluids; a change in diet; pregnancy; lack of exercise; old age; IBS, and some drugs such as antacids containing aluminium or painkillers containing codeine.
In many cases, lifestyle advice can resolve the problem; increasing fibre in the diet, drinking more fluid and taking regular exercise will help. If there is no change, a laxative may be needed.
Bulk-forming laxatives, such as bran or ispaghula, retain water in the bowel making the stools softer and more bulky. This encourages the bowel to move faster. They can take 24 to 48 hours to work, and should be taken with plenty of water.
Osmotic laxatives, such as lactulose, also help to retain water in the bowel. They can take up to three days to work and the patient should also increase their fluid intake.
Stimulant laxatives, including senna and bisacodyl, irritate the bowel making it contract and move faster. They take effect in about eight hours, so should be taken at night to work the following morning. With long-term use, the bowel can become lazy making the constipation worse, so stimulant laxatives should be used for only a few days to get back into a regular pattern.
For this patient, the best approach is to talk through the lifestyle changes and see if that resolves the problem. If not, a bulk-forming or osmotic laxative would be the best choice.
Case study 4: Diarrhoea
A couple come to the counter for something for diarrhoea; they have been away on holiday and it started a few days before their return. Diarrhoea is when bowel movements become more frequent than is normal for that person. The stools are usually looser or more watery.
Common causes include a change in diet, food poisoning, poor hygiene, food intolerance or allergy, IBS and alcohol. Diarrhoea can be a side effect of some medicines such as orlistat or antacids containing magnesium.
Deciding if the patient needs treatment is based on the situation. All patients should be advised to increase their intake of clear fluids (not milk) to replace the water they are losing. Oral rehydration sachets can be used to correct any electrolyte imbalance and should be made up as directed on the packaging.
Diarrhoea after a visit to a developed country is usually caused by a change in diet and will resolve quite quickly once the patient is back at home. If they have visited a developing country or have symptoms such as fever or passing blood, they may have an infection and should be referred to the GP. Diarrhoea caused by food poisoning is best left untreated while the body gets rid of the cause, although oral rehydration sachets may be taken.
Antidiarrhoeals such as loperamide reduce bowel motility and slow the progress of the faeces. This allows more water to be absorbed from the bowel and controls diarrhoea quickly. They should not be used if an infection or food poisoning is suspected, as it will prevent the body getting rid of the cause. Once the patient is feeling better and eating normally, loperamide can be used if the diarrhoea continues. Combination products with simeticone can help with stomach cramps.
Refer to the pharmacist when patients are…
● taking any other medication, either prescribed or over the counter ● complaining of other symptoms including chest pain, shortness of breath, bleeding, fever or unexpected weight loss ● Pregnant or breastfeeding women ● elderly or young children ● aged over 45 years and experiencing new symptoms
Your next steps
● Look at the different heartburn remedies available from your pharmacy, make sure you know how they work and who they are suitable for ● Discuss with a colleague what lifestyle advice you could give someone suffering from IBS or constipation ● Think about what precautions someone can take while on holiday to avoid developing diarrhoea