Symptoms in the Pharmacy :Gastrointestinal Tract Problems(6)

Indigestion

Indigestion (dyspepsia) is commonly presented in community pharmacies

and is often self-diagnosed by patients, who use the term to

include anything from pain in the chest and upper abdomen to lower

abdominal symptoms.

Many patients use the terms indigestion and

heartburn interchangeably. The pharmacist must establish whether

such a self-diagnosis is correct and exclude the possibility of serious

disease.

What you need to know

• Symptoms
• Age
• Adult, child
• Duration of symptoms
• Previous history
• Details of pain
• Where is the pain?
• What is its nature?
• Is it associated with food?
• Is the pain constant or colicky?
• Are there any aggravating or relieving factors?
• Does the pain move to anywhere else?
• Associated symptoms
• Loss of appetite
• Weight loss
• Nausea/vomiting
• Alteration in bowel habit
• Diet
• Any recent change of diet?
• Alcohol consumption
• Smoking habit
• Medication
• Medicines already tried
• Other medicines being taken

Significance of questions and answers

Symptoms

The symptoms of typical indigestion include poorly localised upper

abdominal (the area between the belly button and the breastbone)

discomfort which may be brought on by particular foods, excess food,

alcohol or medication (e.g. aspirin).

Age

Indigestion is rare in children, who should be referred to the doctor.

Abdominal pain, however, is a common symptom in children and is

often associated with an infection. OTC treatment is not appropriate

for abdominal pain of unknown cause and referral to the doctor

would be advisable.

Be cautious when dealing with first-time indigestion in patients aged

45 or over and refer them to the GP for a diagnosis. Gastric cancer,

while rare in young patients, is more likely to occur in those aged 50

and over. Careful history-taking is therefore of paramount importance

here.

Duration/previous history

Indigestion that is persistent or recurrent should be referred to the

doctor, after considering the information gained from questioning.

Any patient with a previous history of the symptom which has not

responded to treatment, or which has worsened, should be referred.

Details of pain/associated symptoms

If the pharmacist can obtain a good description of the pain, then the

decision whether to advise treatment or referral is much easier. A few

medical conditions that may present as indigestion but which require

referral are described below.

Ulcer

Ulcers may occur in the stomach (gastric ulcer) or in the first part of

the small intestine leading from the stomach (duodenal ulcer). Duodenal

ulcers are more common and have different symptoms from

gastric ulcers. Typically the pain of a duodenal ulcer is localised to the

upper abdomen, slightly to the right of the midline. It is often possible

to point to the site of pain with a single finger. The pain is dull and is

most likely to occur when the stomach is empty, especially at night. It

is relieved by food (although it may be aggravated by fatty foods) and

antacids.

The pain of a gastric ulcer is in the same area but less well localised.

It is often aggravated by food and may be associated with nausea and

vomiting. Appetite is usually reduced and the symptoms are persistent

and severe. Both types of ulcer are associated with H. pylori infection

and may be exacerbated or precipitated by smoking and NSAIDs.

Gallstones

Single or multiple stones can form in the gall bladder, which is situated

beneath the liver. The gall bladder stores bile. It periodically contracts

to squirt bile through a narrow tube (bile duct) into the duodenum to

aid the digestion of food, especially fat. Stones can become temporarily

stuck in the opening to the bile duct as the gall bladder contracts.

This causes severe pain (biliary colic) in the upper abdomen below the

right rib margin. Sometimes this pain can be confused with that of a

duodenal ulcer. Biliary colic may be precipitated by a fatty meal.

Gastro-oesophageal reflux

When a person eats, food passes down the gullet (oesophagus) into the

stomach. Acid is produced by the stomach to aid digestion. The lining

of the stomach is resistant to the irritant effects of acid, whereas the

lining of the oesophagus is readily irritated by acid. A sphincter (valve)

system operates between the stomach and the oesophagus preventing

reflux of stomach contents.

When this valve system is weak, e.g. in the presence of a hiatus

hernia, or where sphincter muscle tone is reduced by drugs such as

anticholinergics, theophylline and calcium channel blockers, the acid

contents of the stomach can leak backwards into the oesophagus. The

symptoms arising are typically described as heartburn but many patients

use the terms heartburn and indigestion interchangeably. Heartburn

is a pain arising in the upper abdomen passing upwards behind

the breastbone. It is often precipitated by a large meal, or by bending

and lying down. Heartburn can be treated by the pharmacist but

sometimes requires referral .

Irritable bowel syndrome (IBS)

IBS is a common, non-serious but troublesome condition in which

symptoms are caused by colon spasm (also see p. 122). There is

usually an alteration in bowel habit, often with alternating constipation

and diarrhoea. The diarrhoea is typically worse first thing in

the morning. Pain is usually present. It is often lower abdominal

(below and to the right or left of the belly button) but it may be

upper abdominal and therefore confused with indigestion. Any persistent

alteration in normal bowel habit is an indication for referral.

Atypical angina

Angina is usually experienced as a tight, painful constricting band

across the middle of the chest. Atypical angina pain may be felt in

the lower chest or upper abdomen. It is likely to be precipitated by

exercise or exertion. If this occurs, referral is necessary.

More serious disorders

Persisting upper abdominal pain, especially when associated with

anorexia and unexplained weight loss, may herald an underlying

cancer of the stomach or pancreas. Ulcers sometimes start bleeding,

which may present with blood in the vomit (haematemesis) or in the

stool (melaena). In the latter the stool becomes tarry and black. Urgent

referral is necessary.

Diet

Fatty foods and alcohol can cause indigestion, aggravate ulcers and

precipitate biliary colic.

Smoking habit

Smoking predisposes to, and may cause, indigestion and ulcers. Ulcers

heal more slowly and relapse more often during treatment in smokers.

The pharmacist is in a good position to offer advice on smoking

cessation, perhaps with a recommendation to use NRT.

Medication

Medicines already tried

Anyone who has tried one or more appropriate treatments without

improvement or whose initial improvement in symptoms is not maintained

should see the doctor.

Other medicines being taken

GI side-effects can be caused by many drugs, so it is important

for the pharmacist to ascertain any medication that the patient is

taking.

NSAIDs have been implicated in the causation of ulcers and bleeding

ulcers, and there are differences in toxicity related to increased

doses and to the nature of individual drugs. Sometimes these

drugs cause indigestion. Elderly patients are particularly prone to

such problems and pharmacists should bear this in mind. Severe or

prolonged indigestion in any patient taking an NSAID is an indication

for referral. Particular care is needed in elderly patients, when referral

is always advisable. A study looked at emergency admissions to

two hospitals in two areas of England for GI disease. When the

results were extrapolated to the UK, the number of NSAID-associated

emergency admissions in the UK per year would be about 12 000, with

about 2500 deaths.

OTC medicines also require consideration; aspirin, ibuprofen and

iron are among those that may produce symptoms of indigestion.

Some drugs may interact with antacids; these include antibacterials

(the absorption of most tetracyclines, e.g. azithromycin, cefaclor,

ciprofloxazin, itraconazole and ketoconazole, may be reduced if

taken at the same time as antacids) and iron preparations. Absorption

of ACE inhibitors, phenothiazines, sulpiride, gabapentin and phenytoin

may also be reduced. See the BNF for a full current list. Taking

the doses of antacids and other drugs at least 1 h apart should minimise

the interaction.