How pharmacy teams can advise and support patients with gastrointestinal symptoms

Up to 86 per cent of all British adults have experienced some form of gastrointestinal problem or ailment in the previous year, according to Mintel. Stress was the most likely contributing factor, followed by a poor diet and a lack of sleep. Women experience symptoms more often than men, with the top three ailments being wind, bloating or flatulence, followed by indigestion and diarrhoea.

Many people with GI symptoms prefer to try a natural approach first, such as drinking ginger tea, says the Mintel report, and only 34 per cent say they reach for an OTC or prescription remedy. Pharmacies are well placed to offer advice, but over a third of those who experience GI problems or buy GI remedies say they don’t always know which product to use. A large proportion of the population forego treatments altogether.

Heartburn management

Many people experience heartburn or indigestion during the festive season triggered by overindulgence. According to Gaviscon supplier RB UK, pharmacists can take advantage of this with well-stocked and clear fixtures, signposted by easily recognisable, market-leading brands.

“A pharmacist’s role is to help people recognise and understand signs of heartburn and indigestion and use questioning techniques such as WWHAM to provide management advice and treatment options tailored to individual needs and symptoms,” says community pharmacist Terry Maguire.

Short-term heartburn symptoms are usually nothing to worry about, says Alan Moss, chairman of Action Against Heartburn. But if heartburn lasts for more than three weeks, customers should start to think about whether there could be an underlying cause.

Action Against Heartburn distributed posters and leaflets to local pharmacies, GP surgeries and other locations during February, to encourage people to seek help for persistent heartburn. The coalition of 18 charities and other organisations was set up to promote the earlier diagnosis of oesophageal cancer.

Around 8,700 people are diagnosed with this disease each year, and 7,700 die from it. Seventy per cent of UK oesophageal cancer cases are adenocarcinoma (OAC), which is associated with a precursor condition called Barrett’s oesophagus. Barrett’s oesophagus occurs when prolonged exposure to stomach acid starts to affect the lining of the oesophagus, causing heartburn in the chest area.

“If pharmacists notice customers are buying heartburn medicines on a regular basis they should remind them to see their GP,” says Mr Moss.

“Some people are frightened off by the term ‘cancer’, so pharmacists should mention inflammation of the oesophagus or a stomach ulcer instead.”

IBS-friendly diets

Irritable bowel syndrome (IBS) affects 10-15 per cent of people in the UK and includes symptoms such as bloating, gas, abdominal pain, constipation and uncontrolled diarrhoea. It can be treated with OTC remedies, but there are also certain lifestyle measures that customers can try. In a recent Potters Herbals survey, almost a third of adults thought their IBS was directly caused by stress, and more than a third put the rise in IBS down to worsening diets.

“Lots of food, even supposedly ‘healthy’ food is associated with adverse effects on digestive health,” says Dr Emma Derbyshire, from the Henry Potter Advisory Committee. “Fruit and vegetables, for example, adversely affected the digestive health of five per cent in the survey, not much lower than dairy, gluten or wheat. Again, while nuts are relatively healthy in moderation, five per cent stated that nuts give them gas and bloating. This is likely to be due to the tannins in nuts which can be stomach-irritating.”

A low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and polyols) diet is now an established treatment for IBS, but it is controversial and challenging to follow. It requires the restriction of certain carbohydrates, including foods such as wheat, barley, onion and legumes, foods rich in free fructose (including many fruits), and artificially sweetened products.

In the right people, a low-FODMAP diet can be highly effective, but identifying those individuals is currently impossible. But research published as part of United European Gastroenterology week found that bacterial profiles in the faeces differ between people who do and don’t respond to a low-FODMAP diet, allowing doctors to predict who might benefit most from this type of diet.

“A low-FODMAP diet has been shown in a recent clinical trial to significantly reduce the symptoms of IBS in around half of the people who tried it,” says Dr Sean Bennet, from the University of Gothenburg. “Unfortunately this is a very demanding diet that requires the exclusion of entire food groups, so we have been looking at ways to predict who will gain the greatest benefit.”

Patients who didn’t respond to the low- FODMAP diet were found to have more abnormalities in their gut bacterial profiles before they started the diet than those who did respond. This raises the possibility that faecal bacterial profiling could be undertaken before dietary interventions are considered, says Dr Bennet. “Being able to predict if a patient is unlikely to respond to a low-FODMAP diet means that other therapies could be discussed earlier, and these patients could be spared a demanding diet that might have no effect, or even worsen, their symptoms.”

Probiotics for gut health

Probiotics have been shown to play an essential role in gut health, as many digestive complaints, including IBS and bloating, can be linked to a bacterial imbalance in the gut. Research shows that not all probiotic cultures are the same, so it’s essential that pharmacists look carefully at the products they stock and advise customers to try out different probiotics to see which is most effective for them.

“Several randomised controlled trials have now shown benefits from taking probiotics in functional gut disease,” says gastroenterologist Dr Simon Smale, member of the IBS Network board of trustees. It generally takes 10-14 days of taking a probiotic before significant changes in the gut flora occur, and the microbiome returns to its original constituent bacteria over a similar period once probiotics are stopped.

Many strains of bacteria are unable to survive the harsh environment they have to pass through before they reach the colon, so people need to be taking enough of the right strains of bacteria to ensure positive benefits. “It seems unlikely that one strain of bacteria will work for every person, given the differences in both our human DNA and our individual diets,” says Dr Smale.

Coeliac diagnosis

Around one in 100 people in the UK have coeliac disease, but it’s estimated that half a million more have the condition but are yet to be diagnosed. Currently, the average period from the onset of symptoms to the diagnosis of coeliac disease is 13 years.

The UK’s first online assessment for coeliac disease (www.isitcoeliacdisease. org.uk), developed by Coeliac UK, has now been completed by over 50,000 people searching for an explanation for their symptoms. A confirmed diagnosis of coeliac disease enables people to receive appropriate follow-up care and support,
as well as providing evidence for close family members to be tested.

The online assessment is a useful tool for pharmacists to recommend to customers who experience possible symptoms such as bloating, diarrhoea, nausea, wind, constipation, tiredness, sudden or unexpected weight loss, hair loss and anaemia.

Since its launch in May 2015, around 87 per cent of people who have completed the online assessment have been advised to go to their GP for further tests. “We are very pleased that so many have already taken the assessment, but there is still a long way to go to find the missing half a million undiagnosed people,” says Sarah Sleet, chief executive of Coeliac UK. “So I urge everyone to check their symptoms through our online assessment tool, and if the symptoms are related to coeliac disease, go to your doctor and ask for a blood test. But don’t stop eating gluten until you are tested, otherwise critical blood tests may give a false negative result.”